Why hypoallergenic feed is beneficial for infants with CMPA
- Food allergies such as CMPA deplete intestinal flora that confers immunity and tolerance towards various allergens.6
- Prebiotics modulates gut microbiota and immune function and has anti-inflammatory properties.2
- Prebiotic supplemented infant feeds have shown a beneficial effect in reducing the incidence of atopic dermatitis, wheezing, urticaria, and asthma.10
Infants are at an increased risk of developing food allergies due to immature gut microbiota. Research has shown that gut microbiota has a direct impact on the rapidity of tolerance development towards various allergens.1 Human milk oligosaccharides (HMOs) can exert immunogenic effects and maintain gut health. 2 Prebiotics GOS/FOS in infant feeds could mimic the beneficial effect of HMO 3 and may useful in children with Cow’s Milk Protein Allergy (CMPA).
Amongst the most common food allergies, CMPA is seen to affect children below 1 year of age.4,5 It often manifests in infants within one week after the introduction of cow’s milk protein.6 The worldwide prevalence of CMPA is usually between 2-5%.5 Whereas in India, it affects 1.5- 3% of children during the first year of life.7 Evidence suggests that altered microbial signature and aberrant immune responses play an important role in the pathogenesis of allergy.8
Type of feeding influences the gastrointestinal bacterial growth which has been associated with immune responses and tolerance development.9 One of the key ingredients of infant feed is prebiotics that promotes the development of the right type of infant gut bacteria thereby strengthening the intestinal mucosal immune system.2 Hence, in non-exclusively breastfed infants, switching to hypoallergenic feed containing prebiotic mixture fructo-oligosaccharides (FOS) and galacto-oligosaccharides (GOS) may help in the management of CMPA.10
Need for hypoallergenic feed
CMPA is an immunological response of the body to the protein found in cow’s milk. Almost 90% of the children diagnosed with CMPA in infancy can develop tolerance to cow’s milk protein by three years of age.11 Although IgE is not a diagnostic marker of CMPA; the level of IgE in the body is seen to influence the speed of tolerance development.11 Lower levels of IgE induce rapid development of tolerance towards cow’s milk protein.7 Therefore, hypoallergenic feed containing low allergenic peptides that reduce IgE levels are more preferred in the treatment of CMPA for infants.11 Hypoallergenic feed is described by the American Academy of Pediatrics as a feed that can effectively treat at least 90% of the children with CMPA, with a confidence interval of 95%.12
Role of prebiotics
Studies established the role of intestinal microorganisms’ in influencing tolerance and shaping the outcomes of food allergies during infancy13. Food allergies modulate gut flora that impacts the ability to acquire tolerance towards causative antigens.1,11
Human Milk Oligosaccharides (HMOs) found naturally in breast milk act as natural prebiotics that helps the bifidobacteria to flourish leading to optimal gut health.2 Acting through various mechanisms, HMOs exert anti-bacterial, anti-viral, and anti-inflammatory protective effects thereby developing strong immunity and ability to build tolerance.2 Feeds containing GOS/FOS mixtures have demonstrated increase in the number and metabolic activity of Bifidobacterium and Lactobacillus comparable to breastfed infants, thereby reducing allergies.3,9, 14-15
Benefits of prebiotic-containing hypoallergenic feed
The advent of atopic dermatitis in infants is typically seen to be followed by rhinoconjunctivitis, wheezing, and asthma coined the ‘pediatric allergy march’.15 Multiple studies have reported that the onset of ‘allergy march’ in infants can be delayed by altering the gut microbiota profile by the early dietary intervention.10
Araslanoglu et al. (2007) have progressively studied and successfully demonstrated the immunomodulatory effect of prebiotic containing infant feeds. They reported a significant reduction in the incidence of atopic dermatitis and various infections in high-risk infants following dietary intervention for 6 months.16
They also demonstrated that the immunomodulatory impact of early intervention with a mixture of short- and long-chain oligosaccharides in the first 2 weeks of life. Reduced incidence of atopic dermatitis and various infections was noted well after 18 months of ceasing the intervention. During the first 2 years of life, infants on the intervention had significantly fewer episodes of upper respiratory tract infections, fever episodes, and need for antibiotics.17
In this same cohort of infants, they further demonstrated that the protective impact of the dietary intervention was long-lasting for five years. The study inferred a cumulative reduction in the 5-year incidence of atopic dermatitis from 38% to 19% (50%) and allergic presentations reduced by 80%.10
Acquiring the right intestinal flora through the right dietary intervention during the postnatal period confers immunity against multiple allergic manifestations. Hypoallergenic feeds supplemented with GOS and FOS can modulate the infant gut microbiome leading to reduced incidence of atopic dermatitis, wheezing, urticaria, and asthma.
- Peroni DG, Nuzzi G, Trambusti I, Di Cicco ME, Comberiati P. Microbiome composition and its impact on the development of allergic diseases. Frontiers in immunology. 2020;11: 700.
- Wiciński M, Sawicka E, Gębalski J, Kubiak K, Malinowski B. Human Milk Oligosaccharides: Health Benefits, Potential Applications in Infant Formulas, and Pharmacology. Nutrients. 2020 Jan 20;12(1):266.
- Knol J, Scholtens P, Kafka C, Steenbakkers J, Gro S, Helm K, Klarczyk M, Schöpfer H, Böckler HM, Wells J. Colon microflora in infants fed formula with galacto- and fructo-oligosaccharides: more like breast-fed infants. J Pediatr Gastroenterol Nutr. 2005 Jan;40(1):36-42.
- Koletzko, S.; Niggemann, B.; Arato, A.; Dias, J.A.; Heuschkel, R.; Husby, S.; Mearin, M.L.; Papadopoulou, A.; Ruemmele, F.M.; Staiano, A.; et al. European Society of Pediatric Gastroenterology, Hepatology, and, Nutrition. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J. Pediatr. Gastroenterol. Nutr. 2012, 55, 221–229.
- do Nascimento Rangel AH, Sales DC, Urbano SA, JÚNIOR JG, de Souza MACÊDO C. Lactose intolerance and cow’s milk protein allergy. Ciência e Tecnologia de Alimentos. 2016 Jun;36(2):179-87.
- Vandenplas, Y.; Koletzko, S.; Isolauri, E.; Brueton, M.; Dupont, C.; Hill, D.; Koletzko, S.; Oranje, A.P.;Staiano, A. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch. Dis. Child. 2007, 92, 902–908.
- Matthai J, Sathiasekharan M, Poddar U, Sibal A, Srivastava A, Waikar Y, Malik R, Ray G, Geetha S, Yachha SK. Guidelines on Diagnosis and Management of Cow’s Milk Protein Allergy. Indian Pediatrics. 2020 Aug;57(8):723-9.
- Brosseau C, Selle A, Palmer DJ, Prescott SL, Barbarot S, Bodinier M. Prebiotics: Mechanisms and Preventive Effects in Allergy. Nutrients. 2019 Aug ;11(8):1841.
- Giovannini M, Verduci E, Gregori D, Ballali S, Soldi S, Ghisleni D, Riva E; PLAGOS Trial Study Group. Prebiotic effect of an infant formula supplemented with galacto-oligosaccharides: randomized multicenter trial. J Am Coll Nutr. 2014;33(5):385-93.
- Arslanoglu S, Moro GE, Boehm G, Wienz F, Stahl B, Bertino E. Early Neutral Prebiotic Oligosaccharide Supplentation reduces the incidence of some allergic manifestations in the first 5 years of life. J. Biol. Regul. Homeost. Agents. 2012 Jul;26:49-59.
- Vandenplas Y. Prevention and Management of Cow's Milk Allergy in Non-Exclusively Breastfed Infants. Nutrients. 2017 Jul 10;9(7):731.
- American Academy of Pediatrics. Committee on Nutrition. Pediatrics 2000;106;346. Available at https://pediatrics.aappublications.org/content/106/2/346
- Bunyavanich S, Shen N, Grishin A, Wood R, Burks W, Dawson P, Jones SM, Leung DYM, Sampson H, Sicherer S, Clemente JC. Early-life gut microbiome composition and milk allergy resolution. J Allergy Clin Immunol. 2016 Oct;138(4):1122-1130.
- Brunser O, Figueroa G, Gotteland M, Haschke-Becher E, Magliola C, Rochat F, Cruchet S, Palframan R, Gibson G, Chauffard F, Haschke F. Effects of probiotic or prebiotic supplemented milk formulas on fecal microbiota composition of infants. Asia Pac J Clin Nutr. 2006;15(3):368-76.
- Bakker-Zierikzee AM, Alles MS, Knol J, Kok FJ, Tolboom JJ, Bindels JG. Effects of infant formula containing a mixture of galacto- and fructo-oligosaccharides or viable Bifidobacterium animalis on the intestinal microflora during the first 4 months of life. Br J Nutr. 2005 Nov;94(5):783-90.
- Arslanoglu S, Moro G, Boehm G. Early supplementation of prebiotic oligosaccharides protects formula-fed infants against infections during the first 6 months of life. J Nutr. 2007;137:2420–4.
- Arslanoglu S, Moro GE, Schmitt J, Tandoi L, Rizzardi S, Boehm G. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the first two years of life. The Journal of nutrition. 2008 Jun ;138(6):1091-5.
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