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Use of Infant Formulas in Preventing or Postponing Atopic ManifestationsInfants with a strong family history of allergy are known to be at high risk for the development of atopy. In Kjellman's study (1) predicting cow's milk protein sensitivity, the incidence of cow's milk allergy was 12% in patients with no atopic parent, 20% in those with one atopic parent, 32% in those with one atopic sibling, 43% in those patients with both parents atopic, and up to 72% if both parents had the same atopic symptoms. Comparable results were described by Vandenplas et al. (2), who found a 15% prevalence of major allergy in an unselected control group and 50% in patients with a strong family history of allergy.Multiple interventions have been attempted to reduce the development of allergic disease. These interventions include exclusive breast feeding; maternal avoidance of common allergic foods; use of “hypoallergenic” formula; delayed introduction of allergenic solid foods; reduction of exposure to dust mites, animals, and tobacco smoke; and avoidance of day-care with its attendant risk of infection. Such interventions when used in combination have been successful (3,4), but the importance of an individual intervention (e.g., dietary intervention) has been almost impossible to analyze, given study design flaws in most published reports. There is evidence in the literature to support four infant feeding regimens as prophylaxis against allergic disease: (a) breast feeding, (b) casein hydrolysates, (c) soy formula, and (d) partial whey hydrolysate.BREAST MILKBreast feeding may decrease allergic sensitization by reducing both exposure to and intestinal absorption of food allergens. Intestinal absorption of food allergens, caused by increased intestinal permeability, appears universal in human neonates, with absorption significantly greater in preterm than in term infants (5). The protective role of human breast milk immunoglobulins, especially sIgA, in inhibiting absorption of antigenic substances has been documented in human neonates (6).The benefits of feeding human milk were first shown by Grulee and Sanford (7) in 1936, and later by Matthew et al. (8); there was a sevenfold decrease in the incidence of atopic dermatitis in breast-fed compared with cow's milk-fed infants in the first 6 months of life. Corroborating and contradictory studies have been published since. Prospective studies showing benefit (nine studies) or lack of effect (seven studies) have been critically evaluated by Zeiger et al. (9). They also evaluated nine studies of human postnatal sensitization, through breast milk, of presumably exclusively breast-fed infants. Design problems plagued all the above studies. None of the studies was randomized. Mothers who practice prolonged breast feeding would be expected to delay introduction of solid foods, use less day-care assistance, and smoke less. In addition, “most breast-feeding groups consisted of mothers compliant with study protocol; otherwise they were relegated to the control group” (9). On careful analysis of all of these studies, allergic disease was decreased by (a) prolonged breast feeding (>4 months and preferably 6 months) and (b) delayed solid food introduction (to after 6 months of age) (9).CASEIN HYDROLYSATE FORMULAChandra et al. (10) studied atopic eczema in infants who had a parent with a family history of atopic disease. Mothers who planned to breast feed exclusively were randomly allocated to a restricted diet (avoiding milk and other dairy products, eggs, fish, peanuts, and soybeans) or to a diet with no restrictions. Mothers who did not plan to breast feed were randomly allocated to feed their infants one of three coded formulas: cow's milk, soy milk, and casein hydrolysate (Nutramigen). One gram of calcium supplement was given daily to the women receiving the restricted diet.

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