Divezzamento ed allergie:
quali alimenti quando,
ma soprattutto perchè.
Definition of weaning
To accustom an infant or other young mammal to food other than milk
Thompson D, Fowler HW, Fowler FG, editors.
The concise Oxford dictionary. 9th ed. London: BCA/Oxford University Press, 1996.
The process of accustoming an infant to a full adult diet (while maintaining breastfeeding)
Savage King F, Burgess A. Nutrition for developing countries.
2nd ed. Oxford, United Kingdom: Oxford University Press, 1996:123.
WHO definition of weaning
“complete cessation of breastfeeding”
WHO/UNICEF. Complementary feeding of young children in developing countries:
a review of current scientific knowledge.
Geneva: World Health Organization, WHO/NUT/98.1,1998.
WHO recommandations on weaning
a. timely - foods introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding;
b. adequate - foods provide sufficient energy, protein, and micronutrients to meet a growing child’s nutritional needs;
c. safe - meaning that foods are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats;
d. properly fed - meaning that foods are given consistent with a
child’s signals of appetite and satiety, and that meal frequency and feeding method - actively encouraging the child to consume
sufficient food using fingers, spoon or self-feeding - are suitable for age.
WHO. Complementary feeding.
Report of the global consultation. Geneva, 10-13 December 2001 www.who.int/inf-pr-2001/en/note2001-07.html accessed February 6th, 2005
L’epoca di introduzione degli alimenti solidi nel bambino normale secondo l’OMS è:
1. 3 mesi (60 giorni) 2. 4 mesi (90 giorni) 3. 5 mesi (120 giorni) 4. 6 mesi (150 giorni)
5. Nessuna delle precedenti
WHO recommandations on weaning (2001) WHO Expert Consultation:
• exclusive breastfeeding for six months
• then introduction of complementary foods and continued breastfeeding thereafter
• breastfeeding continue until 12 months of age (thereafter as long as mutually desired).
• breastfeeding can continue beyond 12 months
WHO. Complementary feeding.
Report of the global consultation. Geneva, 10-13 December 2001 www.who.int/inf-pr-2001/en/note2001-07.html accessed February 6th, 2005
Age of introduction of complementary feeding
Introduction of solids “4-6 months”
. Report of a WHO Expert Committee, Technical Report Series 854.
Geneva, World Health Organisation, 1995.
Breastfeeding at 6 months (180 days).
Introduction of solids “around 6 months”
American Academy of Pediatrics. Breastfeeding and use of Human milk.
Pediatrics 1997; 100:1035-9World Health Organization’s Programme of Nutrition.
Complementary feeding of young children in developing countries:
a review of current scientific knowledge. Geneva, World Health Organisation, 1998
WHO recommandations on weaning
Late introduction of solid foods:
• Reduced growth [breast milk alone is insufficient after 6 months]
• Immune protection compromised
• Micronutrient deficiencies
• Motor skills such [chewing] delayed
• Infant unwilling to accept new tastes and textures
WHO. Complementary feeding.
Report of the global consultation. Geneva, 10-13 December 2001 www.who.int/inf-pr-2001/en/note2001-07.html accessed February 6th, 2005
WHO recommandations on timing
Early introduction of solid foods
• Less time on the breast, Æ maternal milk production may decline
• the infant will reject the spoon (a hard object)
• Food allergies can develop
• Pathogens Æ diarrhoeal diseases
WHO. Complementary feeding.
Report of the global consultation. Geneva, 10-13 December 2001 www.who.int/inf-pr-2001/en/note2001-07.html accessed February 6th, 2005
Age of introduction of complementary feeding
After six months of age:
– it is difficult to meet nutrient needs from human milk alone
– infants are developmentally ready for other foods – infants are beginning to actively explore their
environment
Naylor AJ, Morrow AL. Developmental readiness of normal full term infants to progress from exclusive breastfeeding to the introduction of complementary foods.
Linkages/Wellstart International, 2001 Lanigan JA. Systematic review concerning the age of introduction of complementary
foods to the healthy full-term infant. Eur J Clin Nutr 2001;55:309–20.
L’epoca di introduzione degli alimenti solidi nel bambino normale secondo l’OMS è:
1. 3 mesi (60 giorni) 2. 4 mesi (90 giorni) 3. 5 mesi (120 giorni) 4. 6 mesi (150 giorni)
5. Nessuna delle precedenti
Il primo alimento solido da introdurre secondo le linee – guida statunitensi è:
1. Mela
2. Riso e cereali senza glutine 3. Frutta fresca
4. Tutte le precedenti
5. Nessuna delle precedenti
Weaning of infants – Brazil
Brasil/Ministério da Saúde/Organização Pan-Americana da Saúde.
Guia alimentar para crianças menores de 2 anos. Serie A . Normas e manuais técnicos no 107. Brasília, DF, Ministério da Saúde; 2002.
Step 1- human milk exclusive up to 6 months.
No water, tea or any other kind of food.
Step 2 - After 6 months, solid food. Keep providing human milk up to 2 years or longer.
Step 3 – Start with cereals, vegetables, meat, fruits three times a day if the child is being breastfed, five times a day if the child is no longer breastfed Step 4 - Complementary food must be offered on
demand, always respecting the child's appetite.
.
Weaning of infants – 4-6 months - UK
1. Baby rice mixed with the infant’s normal milk 2. Vegetables
3. Fruits 4. Cheese
5. Yoghurt or fromage frais
6. Lean meat, all in pureed form.
Foote KD. Weaning of infants. Arch Dis Child 2003;88:488–492
Weaning of infants - UK
7–8 months: wheat and soy
After 9 months of age: egg - fish After 12 months: nut products
Foote KD. Weaning of infants. Arch Dis Child 2003;88:488–492
Weaning timing in Australia
Dietary guidelines for children and adolescents in Australia. Australian National Health and Medical Research Council, endorsed 10 April 2003
Il primo alimento solido da introdurre secondo le linee – guida statunitensi è:
1. Mela
2. Riso e cereali senza glutine 3. Frutta fresca
4. Tutte le precedenti
5. Nessuna delle precedenti
Weaning timing in Australia
Foods should be introduced individually
Initially, new foods should be offered no more often than each five to 10 days, to avoid confusion and rule out the (remote) possibility of food allergy or sensitivity.
Dietary guidelines for children and adolescents in Australia. Australian National Health and Medical Research Council, endorsed 10 April 2003
1. la precocità di introduzione determina allergie 2. il ritardo riduce il tasso di allergie
3. è meglio non introdurre troppi alimenti troppo presto
4. è bene introdurre gli alimenti uno alla volta.
Schema classico
Il pediatra detta i tempi
1. non importa dare gli alimenti presto o tardi
2. possiamo introdurre gli alimenti anche tutti insieme 3. non è rischioso esporre il bambino a molteplicità di
allergeni in epoca precoce
4. non è necessario alcun timing di introduzione degli alimenti se non quello dettato dalla tradizione
Schema alternativo
Tempi e modi del
divezzamento dettati dal farmacista? Dal
supermercato?
A step-by-step introduction of solid foods:
theorical framework
• can an early introduction of solid foods anticipate the development of food allergy?
• can their avoidance prevent the development of food allergy?
• are some foods more allergenic than other foods?
• are some food allergies more persistent than others?
La precoce introduzione degli alimenti solidi
1. incrementa il rischio di dermatite atopica a due anni 2. incrementa il rischio di dermatite atopica a dieci anni
3. si associa con il rischio di allergia respiratoria successiva
4. tutte le precedenti
5. nessuna delle precedenti
Can an early introduction of solid foods anticipate the development of food allergy?
• 1265 New Zealand neonates
• Prospectively followed-up
- solid foods introduced to 4 months / eczema by 2 years
- solid foods introduced to 4 months / recurrent/chronic eczema by 10 years
Fergusson DM. Early solid food feeding and recurrent childhood eczema:
a 10-year longitudinal study. Paediatrics 1990; 86:541-6
Can an early introduction of solid foods anticipate the development of food allergy?
• A prospective observational study
• Effect of different time of introduction of foods on – weight
– gastrointestinal diseases – respiratory illness
– napkin dermatitis
– eczema up to 24 months of age
Forsyth JS. Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life.
BMJ. 1993;306:1572-6.
Can an early introduction of solid foods anticipate the development of food allergy?
Solid food at an early age (< 8 weeks or 8-12 weeks) Ö
×
respiratory illness at 14-26 weeks of ageÖ
×
persistent cough at 14-26 and 27-39 weeks of age Ö×
eczemaForsyth JS. Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life.
BMJ. 1993;306:1572-6.
Eczema and early solid feeding
257 preterm infants Follow-up one year
Number and type of solid foods and risk of eczema
Morgan J. Eczema and early solid feeding in preterm infants.
Arch Dis Child. 2004;89:309-14
Eczema and early solid feeding
Morgan J. Eczema and early solid feeding in preterm infants.
Arch Dis Child. 2004;89:309-14
La precoce introduzione degli alimenti solidi
1. incrementa il rischio di dermatite atopica a due anni 2. incrementa il rischio di dermatite atopica a dieci anni
3. si associa con il rischio di allergia respiratoria successiva
4. tutte le precedenti
5. nessuna delle precedenti
A step-by-step introduction of solid foods:
theorical framework
• can an early introduction of solid foods anticipate the development of food allergy?
• can their avoidance prevent the development of food allergy?
• are some foods more allergenic than other foods?
• are some food allergies more persistent than others?
Tutte le seguenti affermazioni sono vere eccetto:
1. L’introduzione precoce di alimenti incrementa il rischio di allergia alimentare
2. Evitare un alimento previene il rischio di diventarvi allergici
3. Assumere probiotici riduce il rischio di allergia alimentare
4. Alcuni alimenti sono più allergenici 5. Alcune allergie sono più pericolose
Eczema and early solid feeding
642 term infants Follow-up 5½ years
Delayed introduction of solid foods Æ no lower risk of eczema
Zutavern A. The introduction of solids in relation to asthma and eczema.
Arch Dis Child 2004: 89:303-8
Eczema and early solid feeding
a. Late egg Ö× risk for eczema
b. Late egg Ö× risk for preschool wheezing c. Late milk Ö× risk for eczema
Reverse causality?
“…results do not support the guidelines for the prevention of asthma and allergy in general populations stating that the introduction of solids should be delayed for at least 4–6 months. “
Zutavern A. The introduction of solids in relation to asthma and eczema.
Arch Dis Child 2004: 89:303-8
Can avoidance of solid foods prevent the development of food allergy?
• 135 bambini con familiarità allergica, al seno fino a 6 mesi
• gruppo a (70) - a 6 mesi: verdure cotte, mela, pera, cereali a 8 mesi: carne, pesce
a 10 mesi: uovo
• gruppo b (65) - a 3 mesi: patata, carota cotta, cereali, carne a 4 mesi: uovo, pesce
a 5 mesi: frutti diversi, "commercial foods"
a 6 mesi: dieta libera ed estesa
Æ eczema a < b
Æ allergia alimentare a < b
Saarinen UM, Kajosaari M Prophylaxis of atopic disease: role of infant feeding.
Lancet i: 166-167, 1980 Kajosaari M, Saarinen UM Prophylaxis of atopic disease by six months' total solid foods
elimination. Acta Paed Scand 72:411, 1983
GINI (German Infant Nutritional Intervention Study Group)
2252 newborns enrolled (1995-98) 945 formula-fed vs. 865 breastfed
Randomised to four formulae:
CMF: 16% incidence of atopic manifestations OR = 1 eHF – W: 14% incidence of atopic manifestations OR = 0.86 pHF – W: 11% incidence of atopic manifestations OR = 0.65 eHF – C: 9% incidence of atopic manifestations OR = 0.51
Von Berg A, J Allergy Clin Immunol 2003; 111:533-40
A step-by-step introduction of solid foods:
theorical framework
• can an early introduction of solid foods anticipate the development of food allergy?
• can their avoidance prevent the development of food allergy?
• are some foods more allergenic than other foods?
• are some food allergies more persistent than others?
Directive 2000/13/EC
(amended by Directive 2003/89/EC)
1. Cereals containing gluten 2. Crustaceans
3. Eggs 4. Fish
5. Peanuts 6. Soybeans
7. Milk and products thereof (including lactose)
8. Nuts i. e. Almond, Hazelnut, Walnut, Cashew, Pecan nut, Brazil nut, Pistachio nut, Macadamia nut and Queensland nut 9. Celery
10. Mustard
11. Sesame seeds
Perceived Food Allergies. A Report on a representative telephone survey in 10
European countries
Foods reported to induce a FA (adults)
IFAV – EU 5° FW. RedAll project - Preliminary data.
Adults
9,1
5,4
10,9
6,6 8,3
26,2 28,6
6,0
16,1
13,7
20,4
0 10 20 30 40
Fish Seafo
od
Whea t
Meat Eggs
Milk
Frui t
Legum es
Veget abl
es Nuts
Others
Valid cases: N=1290 in % IFAV/REDALL
Perceived Food Allergies. A Report on a representative telephone survey in 10
European countries
Foods reported to induce a FA (children)
Children
8,4
3,0
11,4
7,0
19,0
38,5
29,5
6,7
13,5
9,7
18,1
0 10 20 30 40
Fish Seafo
od
Whea t
Meat Eggs
Milk
Frui t
Legum es
Veget abl
es Nu
ts
Others
Valid cases: N=438 in % IFAV/REDALL
IFAV – EU 5° FW. RedAll project - Preliminary data.
Clinical tolerance
of homogenised kiwifruit
20 children (challenge-confirmed) SPT+ with kiwi
Fresh - Steam-cooked - Homogenised [scalding at 90°C for 5 minutes - purée extraction at 115°C for 15 seconds - stabilisation at 110°C for 15 seconds - pasteurisation for 21 minutes at 65°C]
Double-blinded placebo-controlled food challenge Steam-cooked Æ Neg 19/20
Homogenized Æ Neg 20/20
Fiocchi A. Tolerance of heat-treated kiwi by children with kiwifruit allergy.
Pediatr Allergy Immunol. 2004;15:454-8.
Perceived Food Allergies. A Report on a representative telephone survey in 10
European countries
Allergy to meat and meat products in children
IFAV – EU 5° FW. RedAll project - Preliminary data.
0
4,7 4,5 1
4,8
10,4
15,2 10,2
9,3 8,7
0 2 4 6 8 10 12 14 16 18 Austria
Belgium Denmark Finland Germany Greece Italy Poland Slovenia Swizerland
A step-by-step introduction of solid foods:
theorical framework
• can an early introduction of solid foods anticipate the development of food allergy?
• can their avoidance prevent the development of food allergy?
• are some foods more allergenic than other foods?
• are some food allergies more persistent than others?
Natural history of egg allergy
Tolerance reached in:
• 44% of case at 2.5 years
• 31% - 51% at 8 years
• 50% at 35 months
• 66% after 5 years
Ford RPK, Taylor B. Natural history of egg hypersensitivity.
Arch Dis Child 1982;57:649-52 García Ara MC. Therapeutic aprroach to and prognosis of food allergy.
Allergol Immunopathol 1996;24(suppl 1):31-5 Boyano-Martinez T. Prediction of tolerance on the basis of quantification of egg
white-specific IgE antibodies in children with egg allergy.
J Allergy Clin Immunol. 2002;110:304-9
Natural history of peanut allergy
A permanent affliction ?
Bock SA. The natural history of peanut allergy. J Allergy Clin Immunol 1989;83:900-4
Infants can outgrow their peanut allergy 10% at 3 years 30% at 6 years 18% at 5 years 21.5% at 7 years
. Spergel JM. Resolution of childhood peanut allergy. Ann.AllAsthma Immunol 2000;85:473-6.
Tariq SM. Cohort study of peanut and nut sensitisation by age of 4 years. BMJ 1996; 313:514-7.
Hourihane JO. Resolution of peanut allergy: case-control study. BMJ. 1998;316:1271-5.
Skolnick HS. The natural history of peanut allergy. J Allergy Clin Immunol 2001;107:367-74.
Pucar F. Peanut challenge: a retrospective study of 140 patients. Clin Exp Allergy 2001;31:40-6.
Fleischer DM. The natural progression of peanut allergy: Resolution and the possibility of recurrence. J Allergy Clin Immunol. 2003;112:183-9
Natural history of peanut allergy
it is not possible to establish an half-life for a diagnosis of nut allery. These
allergens should be considered as giving indefinitely persistent allergies.
Sicherer SH. Clinical update on peanut allergy.
Ann Allergy Asthma Immunol. 2002;88:350-61
Clinical course of cow's milk protein
allergy/intolerance and atopic diseases in childhood
1-year birth cohort 1,749 newborns 39 CMA (2.22%)
Age (years) Tolerance 95% CI
1 22 (56 %) 40-72
2 30 (77 %) 61-89
3 34 (87 %) 73-96
5 36 (92 %) 79-98
10 36 (92 %) 79-98
15 38 (97 %) 87-100
Høst A. Pediatric Allergy and Immunology 2003; 13 (s15), 23-8
APLV: risultati 2000-2005
Pazienti confermati: 197 (91 M, 56 F) Età media alla diagnosi: 7 mesi ± 9 Vita media della diagnosi: 42 ± 21 mesi
Tutte le seguenti affermazioni sono vere eccetto:
1. L’introduzione precoce di alimenti incrementa il rischio di allergia alimentare
2. Evitare un alimento previene il rischio di diventarvi allergici
3. Assumere probiotici riduce il rischio di allergia alimentare
4. Alcuni alimenti sono più allergenici 5. Alcune allergie sono più pericolose
La tempistica di introduzione degli alimenti nel bambino allergico. Tutte queste affermazioni
sono vere eccetto:
1. Il pesce è stato indicato dopo i 12 mesi 2. L’arachide è stata indicata dopo i 36 mesi
3. Il kiwi è stato indicato dopo i 12 mesi 4. L’uovo è stato indicato dopo i 12 mesi
5. Non vi sono documenti ufficiali
Solid foods in children at risk of allergy
Source Egg Fish
24 months 36 months 12 months 18 months 12 months 12 months
18 months 12 months
Peanuts
Zeiger 36 months
Arshad 12 months
Chandra ??
Von Berg 12 months
Fiocchi A. Dietary Primary Prevention of Food Allergy. Ann Allergy, Asthma
& Immunology 2003; 91: 3-13
Weaning of the infant at risk of allergy
Recommandation Time
Solids 6 months
CM 12 months
Egg 24 months
Nuts, fish 36 months
Zeiger RS. Food allergen avoidance in the preventionof food allergy in infants and children. Pediatrics 2003; 111: 1662-9
La tempistica di introduzione degli alimenti nel bambino allergico. Tutte queste affermazioni
sono vere eccetto:
1. Il pesce è stato indicato dopo i 12 mesi 2. L’arachide è stata indicata dopo i 36 mesi
3. Il kiwi è stato indicato dopo i 12 mesi 4. L’uovo è stato indicato dopo i 12 mesi
5. Non vi sono documenti ufficiali
Alcune considerazioni
1. L’epidemiologia indica che l’esposizione precoce si associa ad allergia specifica
2. L’epidemiologia indica che ci sono nuove allergie anche in Italia
3. Non ci sono evidenze che un carico allergenico sia tollerogeno in epoca postnatale
4. Evitare gli alimenti ritarda o riduce la sensibilizzazione e l’allergia
5. Gli alimenti processati possono essere meno allergizzanti 6. In assenza di evidenze, vale il principio di precauzione.
Considerations to be factored when calculating an
“allergenicity index” for each food in a given population
Sensitisation Sensitised/exposed Allergy Symptomatic/sensitised Persistence Persistent/allergic Personal risk Familiarity
1. la precocità di introduzione determina allergie 2. il ritardo riduce il tasso di allergie
3. è meglio non introdurre troppi alimenti troppo presto
4. è bene introdurre gli alimenti uno alla volta.
