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Early regular egg exposure in infants with eczema: A randomized controlled trial

      Background

      Observational studies suggest that early regular ingestion of allergenic foods might reduce the risk of food allergy.

      Objective

      We sought to determine whether early regular oral egg exposure will reduce subsequent IgE-mediated egg allergy in infants with moderate-to-severe eczema.

      Methods

      In a double-blind, randomized controlled trial infants were allocated to 1 teaspoon of pasteurized raw whole egg powder (n = 49) or rice powder (n = 37) daily from 4 to 8 months of age. Cooked egg was introduced to both groups after an observed feed at 8 months. The primary outcome was IgE-mediated egg allergy at 12 months, as defined based on the results of an observed pasteurized raw egg challenge and skin prick tests.

      Results

      A high proportion (31% [15/49]) of infants randomized to receive egg had an allergic reaction to the egg powder and did not continue powder ingestion. At 4 months of age, before any known egg ingestion, 36% (24/67) of infants already had egg-specific IgE levels of greater than 0.35 kilounits of antibody (kUA)/L. At 12 months, a lower (but not significant) proportion of infants in the egg group (33%) were given a diagnosis of IgE-mediated egg allergy compared with the control group (51%; relative risk, 0.65; 95% CI, 0.38-1.11; P = .11). Egg-specific IgG4 levels were significantly (P < .001) greater in the egg group at both 8 and 12 months.

      Conclusion

      Induction of immune tolerance pathways and reduction in egg allergy incidence can be achieved by early regular oral egg exposure in infants with eczema. Caution needs to be taken when these high-risk infants are first exposed to egg because many have sensitization already by 4 months of age.

      Key words

      Abbreviations used:

      IQR (Interquartile range), kUA/L (Kilounits of antibody per liter), RR (Relative risk), SPT (Skin prick test)
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      References

        • Osborne N.J.
        • Koplin J.J.
        • Martin P.E.
        • Gurrin L.C.
        • Lowe A.J.
        • Matheson M.C.
        • et al.
        Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants.
        J Allergy Clin Immunol. 2011; 127: 668-676.e2
        • Mullins R.J.
        Paediatric food allergy trends in a community-based specialist allergy practice, 1995-2006.
        Med J Aust. 2007; 186: 618-621
        • American Academy of Pediatrics
        Committee on nutrition. Hypoallergenic infant formulas.
        Pediatrics. 2000; 106: 346-349
        • Agostoni 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 Gastrenterol Nutr. 2008; 46: 99-110
        • Greer 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 hydrolysed formulas.
        Pediatrics. 2008; 121: 183-191
        • Host 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: 1-4
        • Prescott S.L.
        • Smith P.
        • Tang M.
        • Palmer D.J.
        • Sinn J.
        • Huntley S.J.
        • et al.
        The importance of early complementary feeding in the development of oral tolerance: concerns and controversies.
        Pediatr Allergy Immunol. 2008; 19: 375-380
        • Smith K.M.
        • Eaton A.D.
        • Finlayson L.M.
        • Garside P.
        Oral tolerance.
        Am J Respir Crit Care Med. 2000; 162: S175-S178
        • Brozek J.L.
        • Terracciano L.
        • Hsu J.
        • Kreis J.
        • Compalati E.
        • Santesso N.
        • et al.
        Oral immunotherapy for IgE-mediated cow's milk allergy: a systematic review and meta-analysis.
        Clin Exp Allergy. 2012; 42: 363-374
        • Burks A.W.
        • Jones S.M.
        • Wood R.A.
        • Fleischer D.M.
        • Sicherer S.H.
        • Lindblad R.W.
        • et al.
        Oral immunotherapy for treatment of egg allergy in children.
        N Engl J Med. 2012; 367: 233-243
        • Alm B.
        • Aberg N.
        • Erdes L.
        • Mollborg P.
        • Pettersson R.
        • Norvenius S.G.
        • et al.
        Early introduction of fish decreases the risk of eczema in infants.
        Arch Dis Child. 2009; 94: 11-15
        • Filipiak B.
        • Zutavern A.
        • Koletzko S.
        • von Berg A.
        • Brockow I.
        • Grubl A.
        Solid food introduction in relation to eczema: results from a four-year prospective birth cohort study.
        J Pediatr. 2007; 151: 352-358
        • Hesselmar B.
        • Saalman R.
        • Rudin A.
        • Adlerberth I.
        • Wold A.
        Early fish introduction is associated with less eczema, but not sensitization, in infants.
        Acta Paediatr. 2010; 99: 1861-1867
        • Kull 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: 1009-1015
        • Snijders B.E.
        • Thijs C.
        • van Ree R.
        • van den Brandt P.A.
        Age at first introduction of cow milk products and other food products in relation to infant atopic manifestations in the first 2 years of life: the KOALA Birth Cohort Study.
        Pediatrics. 2008; 122: e115-e122
        • Virtanen S.M.
        • Kaila M.
        • Pekkanen J.
        • Kenward M.G.
        • Uusitalo U.
        • Pietinen P.
        • et al.
        Early introduction of oats associated with decreased risk of persistent asthma and early introduction of fish with decreased risk of allergic rhinitis.
        Br J Nutr. 2010; 103: 266-273
        • Zutavern A.
        • von Mutius E.
        • Harris J.
        • Mills P.
        • Moffat S.
        • White C.
        The introduction of solids in relation to asthma and eczema.
        Arch Dis Child. 2004; 89: 303-308
        • Koplin J.J.
        • Osborne N.J.
        • Wake M.
        • Martin P.E.
        • Gurrin L.C.
        • Robinson M.N.
        • et al.
        Can early introduction of egg prevent egg allergy in infants? A population-based study.
        J Allergy Clin Immunol. 2010; 126: 807-813
        • Hill D.J.
        • Hosking C.S.
        • de Benedictis F.M.
        • Oranje A.P.
        • Diepgen T.L.
        • Bauchau V.
        Confirmation of the association between high levels of immunoglobulin E food sensitization and eczema in infancy: an international study.
        Clin Exp Allergy. 2008; 38: 161-168
        • Kunz B.
        • Oranje A.P.
        • Labreze L.
        • Stalder J.-F.
        • Ring J.
        • Taieb A.
        Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis.
        Dermatology. 1997; 195: 10-19
        • Monti G.
        • Muratore M.C.
        • Peltran A.
        • Bonfante G.
        • Silvestro L.
        • Oggero R.
        • et al.
        High incidence of adverse reactions to egg challenge on first known exposure in young atopic dermatitis children: predictive value of skin prick test and radioallergosorbent test to egg proteins.
        Clin Exp Allergy. 2002; 32: 1515-1519
        • Martino D.J.
        • Bosco A.
        • McKenna K.L.
        • Hollams E.
        • Mok D.
        • Holt P.G.
        • et al.
        T-cell activation genes differentially expressed at birth in CD4+ T-cells from children who develop IgE food allergy.
        Allergy. 2011; 67: 191-200
        • Smith M.
        • Tourigny M.R.
        • Noakes P.
        • Thornton C.A.
        • Tulic M.K.
        • Prescott S.L.
        Children with egg allergy have evidence of reduced neonatal CD4(+)CD25(+)CD127(lo/-) regulatory T cell function.
        J Allergy Clin Immunol. 2008; 121 (e1-7): 1460-1466
        • Jurado-Palomo J.
        • Fiandor-Roman A.M.
        • Bobolea I.D.
        • Sanchez-Pastor S.
        • Pascual C.Y.
        • Quirce S.
        Oral challenge with pasteurized egg white from Gallus domesticus.
        Int Arch Allergy Immunol. 2009; 151: 331-335

      Reference

        • Caubet J.C.
        • Bencharitiwong R.
        • Moshier E.
        • Godbold J.H.
        • Sampson H.A.
        • Nowak-Wegrzyn A.
        Significance of ovomucoid- and ovalbumin-specific IgE/IgG(4) ratios in egg allergy.
        J Allergy Clin Immunol. 2012; 129: 739-747

      Linked Article

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        Journal of Allergy and Clinical ImmunologyVol. 133Issue 2
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          We read with interest the recent study of Palmer et al1 addressing the problem of induction of immune tolerance in infants with eczema. In this study children received 1 teaspoon (0.9 g) of pasteurized raw whole egg powder (equivalent to one sixth of an egg, n = 49) or rice powder (control, n = 37) daily from 4 to 8 months of age; 15 children had allergic reactions to raw egg powder and therefore did not continue powder ingestion. Cooked egg (one sixth of a mashed, hard-boiled whole egg) was given to both groups at 8 months in an oral food challenge.
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        Journal of Allergy and Clinical ImmunologyVol. 132Issue 6
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          We read with interest the article “Early regular egg exposure in infants with eczema: A randomized controlled trial” by Palmer et al.1 The authors attempted a well-designed study to evaluate the role of early exposure to potentially allergenic foods. The primary outcome of reduction in the risk of IgE-mediated egg allergy was not met, and the difference between the 2 groups was not statistically significant (33% in the study group vs 51% in the control group; relative risk, 0.65; 95% CI, 0.38-1.11; P = .11).
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