Portal de Periódicos da CAPES

Maternal and infant diets for prevention of allergic diseases: Understanding menu changes in 2008

2008; Elsevier BV; Volume: 122; Issue: 1 Linguagem: Inglês

10.1016/j.jaci.2008.05.019

1097-6825

Scott H. Sicherer, A. Wesley Burks,

Child Nutrition and Feeding Issues

In 2000, the American Academy of Pediatrics (AAP) Committee on Nutrition published recommendations aimed at minimizing the risk of atopic diseases in infants considered high-risk.1American Academy of PediatricsCommittee on NutritionHypoallergenic infant formulas.Pediatrics. 2000; 106: 346-349Crossref PubMed Scopus (269) Google Scholar The committee noted that conclusive studies were not available for making definite recommendations, but they advised avoidance of certain foods by pregnant and breast-feeding women as well as by infants and young children. This year, the AAP's Committee on Nutrition and Section on Allergy and Immunology published an updated Clinical Report reviewing recent and historical data regarding the impact of nutritional interventions on the development of atopic disease in infants and children.2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar Included in the report are revised statements that replace the former recommendations. In this Editorial, we review the updated report, compare it to recommendations from other professional societies, and entertain some of the vexing issues that allergists must consider as we advise patients and primary care physician colleagues. We do not attempt an extensive review of these topics, because there are multiple excellent reviews and committee reports3Fiocchi A. Assa'ad A. Bahna S. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology.Ann Allergy Asthma Immunol. 2006; 97: 10-20Abstract Full Text PDF PubMed Scopus (154) Google Scholar, 4van Odijk J. Kull I. Borres M.P. Brandtzaeg P. Edberg U. Hanson L.A. et al.Breastfeeding and allergic disease: a multidisciplinary review of the literature (1966-2001) on the mode of early feeding in infancy and its impact on later atopic manifestations.Allergy. 2003; 58: 833-843Crossref PubMed Scopus (360) Google Scholar, 5Devereux G. Seaton A. Diet as a risk factor for atopy and asthma.J Allergy Clin Immunol. 2005; 115: 1109-1117Abstract Full Text Full Text PDF PubMed Scopus (350) Google Scholar, 6Friedman N.J. Zeiger R.S. The role of breast-feeding in the development of allergies and asthma.J Allergy Clin Immunol. 2005; 115: 1238-1248Abstract Full Text Full Text PDF PubMed Scopus (254) Google Scholar, 7Tarini B.A. Carroll A.E. Sox C.M. Christakis D.A. Systematic review of the relationship between early introduction of solid foods to infants and the development of allergic disease.Arch Pediatr Adolesc Med. 2006; 160: 502-507Crossref PubMed Scopus (109) Google Scholar, 8Agostoni C. Decsi T. Fewtrell M. Goulet O. Kolacek S. Koletzko B. et al.Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition.J Pediatr Gastroenterol Nutr. 2008; 46: 99-110Crossref PubMed Scopus (780) Google Scholar, 9Host A. Halken S. Muraro A. Dreborg S. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children.Pediatr Allergy Immunol. 2008; 19: 1-4Crossref PubMed Scopus (195) Google Scholar, 10Brand P.L. Vlieg-Boerstra B.J. Dubois A.E. Dietary prevention of allergic disease in children: are current recommendations really based on good evidence?.Pediatr Allergy Immunol. 2007; 18: 475-479Crossref PubMed Scopus (33) Google Scholar, 11Muraro A. Dreborg S. Halken S. Host A. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children, part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.Pediatr Allergy Immunol. 2004; 15: 291-307Crossref PubMed Scopus (238) Google Scholar; however, we incorporate pertinent studies from the past year.What's similarThe 2008 report presents evidence affirming several previous recommendations that are relatively easy for parents to follow. For example, exclusive breast-feeding for at least 4 months (with a goal of 6 months) versus feeding with a standard cow's milk or soy formula is considered beneficial to delay or prevent atopic dermatitis and milk allergy. If supplementation during that period is needed, then hypoallergenic formulas such as extensive casein hydrolysates, or possibly a less allergenic formula such as a partial whey hydrolysate, is considered beneficial. Roughly similar to the 2000 report, solids are to be avoided until 4 to 6 months of age.What's newA subtle difference in the updated report is that "high risk" infants are defined as those with at least 1 parent or sibling with a documented atopic disease, which is less stringent than the 2000 report and is more similar to definitions in European professional societies' recommendations (Table I). A major difference of the new report is that it avoids making recommendations. Instead, statements about possible dietary changes are made along with evidence (or lack thereof) about efficacy. The new report specifically advises the reader that inadequate study design or a paucity of data limits the ability to draw firm conclusions regarding pregnancy and lactation avoidance diets and the timing of introducing specific "allergenic" complementary foods. It also warns that lack of proven efficacy does not equate to an approach being disproven. Within this context, several of the previous "recommendations" are relegated to "lack of evidence" as summarized in Table I. As noted, the new AAP report is very similar to past and current "recommendations" from European professional groups.8Agostoni C. Decsi T. Fewtrell M. Goulet O. Kolacek S. Koletzko B. et al.Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition.J Pediatr Gastroenterol Nutr. 2008; 46: 99-110Crossref PubMed Scopus (780) Google Scholar, 9Host A. Halken S. Muraro A. Dreborg S. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children.Pediatr Allergy Immunol. 2008; 19: 1-4Crossref PubMed Scopus (195) Google Scholar, 11Muraro A. Dreborg S. Halken S. Host A. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children, part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.Pediatr Allergy Immunol. 2004; 15: 291-307Crossref PubMed Scopus (238) Google Scholar, 12Host A. Koletzko B. Dreborg S. Muraro A. Wahn U. Aggett P. et al.Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition.Arch Dis Child. 1999; 81: 80-84Crossref PubMed Scopus (416) Google ScholarTable IDietary prevention recommendations/comments from several professional organizationsGroup/publicationDefinitions/interventionsAAP 2008 Clinical ReportAAP 2000 recommendationsESPACI/ESPGHAN 1999, ESPGHAN 2008 recommendationsSP-EAACI, 2004, 2008 recommendationsRisk category: "high risk"Parent or sibling with documented allergic diseaseBiparental or parent plus sibling history of allergyParent or sibling affected (1999)Parent or sibling with documented allergic diseasePregnancy avoidanceLack of evidencePossibly peanutNo special diet∗Advice that is the same for those not "high risk."Breast-feed "exclusively" untilEvidence for 3-4 mo (waiting 4-6 mo tied to introducing solids∗Advice that is the same for those not "high risk.")6 mo4-6 mo∗Advice that is the same for those not "high risk."At least 4 mo, prefer 6 mo∗Advice that is the same for those not "high risk."Maternal lactation avoidance of allergensSome evidence for reduced atopic dermatitisPeanuts, tree nuts and "consider" egg, milk, fish, and "perhaps other foods"No special diet∗Advice that is the same for those not "high risk."Prevention formulasCompared with whole cow's milk protein, evidence for certain extensive hydrolysates, partial hydrolysates, but not soy (see text)"Hypoallergenic formula" (extensive hydrolysate, possibly partial hydrolysate); not soy.Confirmed reduced allergenicity (1999)Extensively hydrolyzed until 4 mo of age (2004); documented reduced allergenicity (2008)Types of "solids" and complementary foodsEvidence to wait 4 (to 6) mo; lack of convincing evidence for avoiding specific allergenic foodsSolids held to 6 mo Dairy products, age 1 y Egg, age 2 yPeanuts, nuts, fish, age 3 yNot before 17 wk and no later than 26 wk; no convincing evidence for delaying potentially allergenic foods such as fish, egg (2008)∗Advice that is the same for those not "high risk."No evidence of diet effect after 4-6 moESPACI, European Society for Pediatric Allergology and Clinical Immunology; ESPGHAN, European Society for Pediatric Gastroenterology, Hepatology and Nutrition; SP-EAACI, Section on Pediatrics, European Academy of Allergology and Clinical Immunology.∗ Advice that is the same for those not "high risk." Open table in a new tab The following is a summary of data highlighted in the AAP report, with consideration of practical issues and more recent studies.Diet of pregnant womenA Cochrane database meta-analysis of 4 clinical studies concluded that antigen avoidance during pregnancy is unlikely to reduce the child's risk of developing atopic disease, and dietary restrictions could adversely affect maternal or fetal nutrition.13Kramer M.S. Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child.Cochrane Database Syst Rev. 2006; 3: CD000133PubMed Google Scholar Although the AAP previously suggested pregnant women with atopy risks avoid peanuts, a subsequent study found no evidence of prenatal sensitization from maternal consumption of peanuts.14Lack G. Fox D. Northstone K. Golding J. Factors associated with the development of peanut allergy in childhood.N Engl J Med. 2003; 348: 977-985Crossref PubMed Scopus (752) Google Scholar The AAP report synthesizes these available data, concluding a lack of evidence for maternal pregnancy restriction diets.2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar It should be appreciated that studies have not been undertaken specifically to evaluate exclusion of peanut in atopy "high risk" pregnancies. Recent publications revealed that very few women in the United Kingdom followed dietary peanut exclusion advice, and an effect, positive or negative, was not detectable (although too few evaluable subjects and the observational nature of the reports reduce the ability to make firm conclusions).15Dean T. Venter C. Pereira B. Grundy J. Clayton C.B. Higgins B. Government advice on peanut avoidance during pregnancy: is it followed correctly and what is the impact on sensitization?.J Hum Nutr Diet. 2007; 20: 95-99Crossref PubMed Scopus (41) Google Scholar, 16Hourihane J.O. Aiken R. Briggs R. Gudgeon L.A. Grimshaw K.E. Dunngalvin A. et al.The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry.J Allergy Clin Immunol. 2007; 119: 1197-1202Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar Additional recent studies about pregnancy diets reveal that components other than specific allergens, such as fats, may influence atopy outcomes.17Chatzi L. Torrent M. Romieu I. Garcia-Esteban R. Ferrer C. Vioque J. et al.Mediterranean Diet in pregnancy protective for wheeze and atopy in childhood.Thorax. 2008; 63: 507-513Crossref PubMed Scopus (119) Google Scholar, 18Calvani M. Alessandri C. Sopo S.M. Panetta V. Pingitore G. Tripodi S. et al.Consumption of fish, butter and margarine during pregnancy and development of allergic sensitizations in the offspring: role of maternal atopy.Pediatr Allergy Immunol. 2006; 17: 94-102Crossref PubMed Scopus (104) Google ScholarDiet of lactating womenRegarding maternal lactation diets, a Cochrane database meta-analysis13Kramer M.S. Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child.Cochrane Database Syst Rev. 2006; 3: CD000133PubMed Google Scholar found some evidence for reduced atopic dermatitis, but suggested more studies are needed. The AAP report presents this view. A previous expert review that was not a structured meta-analysis and did not exclude as many studies as the Cochrane review concluded that special maternal lactation avoidance diets were unnecessary.11Muraro A. Dreborg S. Halken S. Host A. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children, part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.Pediatr Allergy Immunol. 2004; 15: 291-307Crossref PubMed Scopus (238) Google ScholarHuman milk versus whole cow's milk formulaFor atopic dermatitis, there appears to be little controversy that human breast milk feeding prevents or delays disease compared with whole cow's milk protein for infants at risk.2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar, 11Muraro A. Dreborg S. Halken S. Host A. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children, part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.Pediatr Allergy Immunol. 2004; 15: 291-307Crossref PubMed Scopus (238) Google Scholar, 19Gdalevich M. Mimouni D. David M. Mimouni M. Breast-feeding and the onset of atopic dermatitis in childhood: a systematic review and meta-analysis of prospective studies.J Am Acad Dermatol. 2001; 45: 520-527Abstract Full Text Full Text PDF PubMed Scopus (384) Google Scholar, 20Laubereau B. Brockow I. Zirngibl A. Koletzko S. Gruebl A. von Berg A. et al.Effect of breast-feeding on the development of atopic dermatitis during the first 3 years of life: results from the GINI-birth cohort study.J Pediatr. 2004; 144: 602-607Abstract Full Text Full Text PDF PubMed Scopus (144) Google ScholarHowever, the evidence on whether human milk is protective against development of asthma is contradictory. There appears to be a protective effect in children younger than 5 years old,21Gdalevich M. Mimouni D. Mimouni M. Breast-feeding and the risk of bronchial asthma in childhood: a systematic review with meta-analysis of prospective studies.J Pediatr. 2001; 139: 261-266Abstract Full Text Full Text PDF PubMed Scopus (416) Google Scholar but breast-feeding by mothers with asthma has been correlated with an increased risk for asthma in older children and adults.22Wright A.L. Holberg C.J. Taussig L.M. Martinez F.D. Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood.Thorax. 2001; 56: 192-197Crossref PubMed Scopus (319) Google Scholar The AAP report2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar presents the benefit (atopic dermatitis) as well as the caveat for asthma associated with breast-feeding. Subsequently, Matheson et al23Matheson M.C. Erbas B. Balasuriya A. Jenkins M.A. Wharton C.L. Tang M.L. et al.Breast-feeding and atopic disease: a cohort study from childhood to middle age.J Allergy Clin Immunol. 2007; 120: 1051-1057Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar reported long-term follow-up from the Tasmanian Asthma study indicating that at age 7 years, participants who had been exclusively breast-fed and had a history of maternal atopy were less likely to have asthma (odds ratio, 0.8; 95% CI, 0.6-1.0), but by age 14 years, the risk reversed (odds ratio, 1.5; 95% CI, 1-2), and by age 44 years, participants were even more likely to have asthma (odds ratio, 1.57; 95% CI, 1.2-2.1). The explanation for this effect could be the reduction of early infection leading to less asthma triggered by infection early in life and later increased atopy because of immune dysregulation for lack of infection (ie, the hygiene hypothesis). Currently, data only support the role of breast-feeding in reducing the likelihood of wheezing in young children.Food allergyThe development of food allergy is closely associated with having atopic dermatitis, and it can be difficult to analyze the effect of nutrition on the development of food allergy alone. In an analysis of peer-reviewed observational and interventional studies, Muraro et al11Muraro A. Dreborg S. Halken S. Host A. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children, part III: critical review of published peer-reviewed observational and interventional studies and final recommendations.Pediatr Allergy Immunol. 2004; 15: 291-307Crossref PubMed Scopus (238) Google Scholar concluded that exclusive breast-feeding for at least 4 months decreases the risk for cow's milk allergy until 18 months in infants at risk of developing atopic diseases. In contrast, a Cochrane review analyzing optimal length of exclusive breast-feeding concluded that at least 4 months of exclusive breast-feeding does not protect against food allergy at 1 year, although the review included only 1 study with a blind food challenge.24Kramer M.S. Kakuma R. Optimal duration of exclusive breastfeeding.Cochrane Database Syst Rev. 2002; 1: CD003517PubMed Google Scholar The AAP report2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar synthesizes the available data, concluding a reduced cumulative incidence of cow's milk allergy for breast-feeding compared with cow's milk in the first 2 years of life.Hydrolyzed formula versus cow milk formulaPartially hydrolyzed and extensively hydrolyzed formulas have been studied for their ability to prevent atopic disease for more than 15 years. Most studies of these formulas have focused on infants at high risk of developing allergy. Although more than 100 published studies have addressed whether hydrolyzed formulas reduce the risk of atopic disease, fewer than 20 were randomized or quasi-randomized.2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar The AAP report2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar relies heavily on data evaluated in a Cochrane database report25Osborn D.A. Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants.Cochrane Database Syst Rev. 2006; 4: CD003664PubMed Google Scholar but excluded several studies in which scientific validity was a concern. In addition, data from the German Infant Nutrition Intervention program was considered.26von Berg A. Koletzko S. Grubl A. Filipiak-Pittroff B. Wichmann H.E. Bauer C.P. et al.The effect of hydrolyzed cow's milk formula for allergy prevention in the first year of life: the German Infant Nutritional Intervention Study, a randomized double-blind trial.J Allergy Clin Immunol. 2003; 111: 533-540Abstract Full Text Full Text PDF PubMed Scopus (378) Google Scholar Subsequently, a 3-year follow-up study from the German Infant Nutrition Intervention trial showed a continued protective effect in the per protocol analysis of atopic dermatitis in high-risk infants not exclusively breast-fed of an extensive casein hydrolysate (odds ratio, 0.53; 95% CI, 0.32-0.88) or partial whey hydrolysate (odds ratio, 0.60; 95% CI, 0.37-0.97), but still no effect on asthma.27von Berg A. Koletzko S. Filipiak-Pittroff B. Laubereau B. Grubl A. Wichmann H.E. et al.Certain hydrolyzed formulas reduce the incidence of atopic dermatitis but not that of asthma: three-year results of the German Infant Nutritional Intervention Study.J Allergy Clin Immunol. 2007; 119: 718-725Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar A particular extensively hydrolyzed whey formula did not show protection. Committee reviewers2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar, 9Host A. Halken S. Muraro A. Dreborg S. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children.Pediatr Allergy Immunol. 2008; 19: 1-4Crossref PubMed Scopus (195) Google Scholar generally synthesize the available data to conclude that compared with a whole cow's milk protein formula, certain studied reduced allergenic formulas have a protective effect on atopic dermatitis, with a slight advantage of the extensively hydrolyzed casein formula (perhaps more effective for those with a stronger atopic family history). The AAP report2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar suggests cost be a consideration in selecting a formula and cautions that amino acid formulas have not been studied for prevention.Introduction of complementary foodsVarious committees have concluded from the available evidence that "solids" should be delayed to 4 to 6 months primarily because the timing of such introduction is tied to the time of exclusive breast-feeding.2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar, 9Host A. Halken S. Muraro A. Dreborg S. Niggemann B. Aalberse R. et al.Dietary prevention of allergic diseases in infants and small children.Pediatr Allergy Immunol. 2008; 19: 1-4Crossref PubMed Scopus (195) Google Scholar On the basis of the nature of the available studies, the updated AAP report2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar has reduced the age of evidence for an effect to 4 months. Subsequent studies continue to fail to show a convincing protective effect of delaying solids.28Filipiak B. Zutavern A. Koletzko S. von Berg A. Brockow I. Grubl A. et al.Solid food introduction in relation to eczema: results from a four-year prospective birth cohort study.J Pediatr. 2007; 151: 352-358Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 29Zutavern A. Brockow I. Schaaf B. von Berg A. Diez U. Borte M. et al.Timing of solid food introduction in relation to eczema, asthma, allergic rhinitis, and food and inhalant sensitization at the age of 6 years: results from the prospective birth cohort study LISA.Pediatrics. 2008; 121: e44-e52PubMed Google Scholar Perhaps more controversial is the previous AAP recommendation for infants at risk of developing atopic disease to avoid milk protein to age 1 year, eggs until 2 years, and peanuts, tree nuts, and fish until 3 years of age.1American Academy of PediatricsCommittee on NutritionHypoallergenic infant formulas.Pediatrics. 2000; 106: 346-349Crossref PubMed Scopus (269) Google Scholar This prevention approach was only studied by Zeiger and Heller,30Zeiger R.S. Heller S. The development and prediction of atopy in high-risk children: follow-up at age seven years in a prospective randomized study of combined maternal and infant food allergen avoidance.J Allergy Clin Immunol. 1995; 95: 1179-1190Abstract Full Text Full Text PDF PubMed Scopus (500) Google Scholar but there was uncertain compliance and high dropout, and there were no clear differences in point prevalence of atopic outcomes or sensitization after age 4 years. Regarding the 2000 AAP report,1American Academy of PediatricsCommittee on NutritionHypoallergenic infant formulas.Pediatrics. 2000; 106: 346-349Crossref PubMed Scopus (269) Google Scholar there are no data about whether these recommendations have been followed, nor any attempts at validation. If the previous AAP advice were followed, presumably an "at risk" but healthy 1-year-old would not have ingested common foods such as butter or biscuits and would not have birthday cake (egg) until age 2 years. On the basis of available data, including the apparent role of exposure to whole proteins in the first months of life being associated with atopic outcomes, and the known allergenicity of foods such as milk, egg, peanut, and fish, a consensus document from the Adverse Reactions to Foods Committee of the American College of Allergy, Asthma and Immunology in 2006 suggested following the 2000 AAP recommendations to avoid these allergens for the prescribed period.3Fiocchi A. Assa'ad A. Bahna S. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology.Ann Allergy Asthma Immunol. 2006; 97: 10-20Abstract Full Text PDF PubMed Scopus (154) Google Scholar In contrast, in a position paper published in January 2008, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition concluded that there is no convincing evidence that avoidance or delayed introduction of potentially allergenic foods, such as fish and eggs, reduces allergies in infants either at risk or not.8Agostoni C. Decsi T. Fewtrell M. Goulet O. Kolacek S. Koletzko B. et al.Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition.J Pediatr Gastroenterol Nutr. 2008; 46: 99-110Crossref PubMed Scopus (780) Google Scholar This European Society for Paediatric Gastroenterology, Hepatology and Nutrition committee recommended that complementary foods be introduced after 17 weeks but no later than 26 weeks. These conclusions were apparently influenced by several negative studies on solid food timing and diversity and by studies showing protective effects of fatty acids in fish31Kull I. Bergstrom A. Lilja G. Pershagen G. Wickman M. Fish consumption during the first year of life and development of allergic diseases during childhood.Allergy. 2006; 61: 1009-1015Crossref PubMed Scopus (216) Google Scholar and possible detrimental effects of waiting longer to introduce wheat32Poole J.A. Barriga K. Leung D.Y. Hoffman M. Eisenbarth G.S. Rewers M. et al.Timing of initial exposure to cereal grains and the risk of wheat allergy.Pediatrics. 2006; 117: 2175-2182Crossref PubMed Scopus (271) Google Scholar or other solids.29Zutavern A. Brockow I. Schaaf B. von Berg A. Diez U. Borte M. et al.Timing of solid food introduction in relation to eczema, asthma, allergic rhinitis, and food and inhalant sensitization at the age of 6 years: results from the prospective birth cohort study LISA.Pediatrics. 2008; 121: e44-e52PubMed Google Scholar The updated AAP report2Greer F.R. Sicherer S.H. Burks A.W. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas.Pediatrics. 2008; 121: 183-191Crossref PubMed Scopus (868) Google Scholar uses the term "no current convincing evidence" regarding protective effects of a delay of solids or specific allergens beyond 4 to 6 months.Deciding what should be on or off the menu in 2008We know that the revised AAP report has caused concern because it is not simply a to-do list of recommendations. The new approach is more sensitive to th