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We found no evidence that regular egg intake from age 4 to 6 months substantially alters the risk of egg allergy by age 1 year in infants who are at hereditary risk of allergic disease and had no eczema symptoms at study entry.

Objective To determine whether dietary n-3 long chain polyunsaturated fatty acid (LCPUFA) supplementation of pregnant women with a fetus at high risk of allergic disease reduces immunoglobulin E associated eczema or food allergy at 1 year of age.Design Follow-up of infants at high hereditary risk of allergic disease in the Docosahexaenoic Acid to Optimise Mother Infant Outcome (DOMInO) randomised controlled trial.Setting Adelaide, South Australia.Participants 706 infants at high hereditary risk of developing allergic disease whose mothers were participating in the DOMInO trial.Interventions The intervention group (n=368) was randomly allocated to receive fish oil capsules (providing 900 mg of n-3 LCPUFA daily) from 21 weeks' gestation until birth; the control group (n=338) received matched vegetable oil capsules without n-3 LCPUFA.Main outcome measure Immunoglobulin E associated allergic disease (eczema or food allergy with sensitisation) at 1 year of age.Results No differences were seen in the overall percentage of infants with immunoglobulin E associated allergic disease between the n-3 LCPUFA and control groups (32/368 (9%) v 43/338 (13%); unadjusted relative risk 0.68, 95% confidence interval 0.43 to 1.05, P=0.08; adjusted relative risk 0.70, 0.45 to 1.09, P=0.12), although the percentage of infants diagnosed as having atopic eczema (that is, eczema with associated sensitisation) was lower in the n-3 LCPUFA group (26/368 (7%) v 39/338 (12%); unadjusted relative risk 0.61, 0.38 to 0.98, P=0.04; adjusted relative risk 0.64, 0.40 to 1.02, P=0.06). Fewer infants were sensitised to egg in the n-3 LCPUFA group (34/368 (9%) v 52/338 (15%); unadjusted relative risk 0.61, 0.40 to 0.91, P=0.02; adjusted relative risk 0.62, 0.41 to 0.93, P=0.02), but no difference between groups in immunoglobulin E associated food allergy was seen.Conclusion n-3 LCPUFA supplementation in pregnancy did not reduce the overall incidence of immunoglobulin E associated allergies in the first year of life, although atopic eczema and egg sensitisation were lower. Longer term follow-up is needed to determine if supplementation has an effect on respiratory allergic diseases and aeroallergen sensitisation in childhood.

Rising rates of food allergies in early childhood reflect increasing failure of early immune tolerance mechanisms. There is mounting concern that the current recommended practice of delaying complementary foods until 6 months of age may increase, rather than decrease, the risk of immune disorders. Tolerance to food allergens appears to be driven by regular, early exposure to these proteins during a 'critical early window' of development. Although the timing of this window is not clear in humans, current evidence suggests that this is most likely to be between 4 and 6 months of life and that delayed exposure beyond this period may increase the risk of food allergy, coeliac disease and islet cell autoimmunity. There is also evidence that other factors such as favourable colonization and continued breastfeeding promote tolerance and have protective effects during this period when complementary feeding is initiated. This discussion paper explores the basis for concern over the current recommendation to delay complementary foods as an approach to preventing allergic disease. It will also examine the growing case for introducing complementary foods from around 4 months of age and maintaining breastfeeding during this early feeding period, for at least 6 months if possible.

Reduced vitamin D status in pregnancy may be a risk factor for the development of eczema in the first year of life, reinforcing the need to explore the role of vitamin D exposure during development for disease prevention.

In sub-Saharan Africa, health systems are fragile and staffing is grossly inadequate to meet rising health needs. Despite growing international attention, donors have been reluctant to undertake the significant investments required to address the human resources problem comprehensively, given social and political sensitivities, and concerns regarding sustainability of interventions and risks of rising donor dependency. In Malawi, one of the poorest nations in Africa, declining human resource levels have fueled an accelerating collapse of public health services since the late 1990s. In an effort to improve health outcomes, in 2004 the government launched a new health initiative to deliver an Essential Health Package, including a major scale-up of HIV and AIDS related services. Improving staffing levels is the single biggest challenge to implementing this approach. Donors agreed to help the government develop an Emergency Human Resources Programme with five main facets: improving incentives for recruitment and retention of staff through salary top-ups, expanding domestic training capacity, using international volunteer doctors and nurse tutors as a stop-gap measure, providing international technical assistance to bolster planning and management capacity and skills, and establishing more robust monitoring and evaluation capacity. Industrial relations were a prominent consideration in determining the shape of the Programme. The combination of short- and long-term measures appears to be helpful in maintaining commitment to the programme.

Symptoms, such as crying, vomiting, and rashes, during infancy are not new, but in the 21st century, many parents attribute them to an underlying cow's milk allergy (CMA). In this Special Communication article, we explore the evidence for managing common infant symptoms by avoiding cow's milk. Prescriptions of specialized formula products for managing CMA have risen steeply since the turn of the 21st century; for example, data from Australia and England show 10-fold rises in amino acid formula prescriptions between 2000 and 2010 and 2005 and 2018, respectively (Figure 1). 1,2 This increased demand for products used to manage CMA is not matched by evidence of an increase in disease prevalence. Although one small Chinese study 3 suggested that CMA and allergic sensitization to milk in children aged up to 2 years may have increased between 1999 (3.2% sensitized and 1.6% allergic; n = 314) and 2009 (6.2% sensitized and 3.5% allergic; n = 401), 3 this was not supported by a larger Australian study 4 that found no change in allergic sensitization to cow's milk at age 12 months in high-risk infants between 1990 and 1994 (2.4%; 95% CI, 1.6-3.1; n = 541) and 2006 and 2010 (2.6%; 95% CI, 2.0-3.4; n = 1893). Similarly, in the United States, there was no change in allergic sensitization to milk (specific IgE Ն2 kU/L) in children aged 6 to 19 years between National Health and Nutrition Exami-IMPORTANCE Sales of specialized formula for managing cow's milk allergy (CMA) have increased, triggering concern that attribution of common infant symptoms, such as crying, vomiting, and rashes, to CMA may be leading to overdiagnosis, which could undermine breastfeeding.OBJECTIVE To understand whether CMA guideline recommendations might promote CMA overdiagnosis or undermine breastfeeding.EVIDENCE REVIEW We reviewed recommendations made in CMA guidelines and critically appraised 2 key recommendations. First, we reviewed relevant literature summarizing whether maternal or infant dietary exclusion of cow's milk is effective for managing common infant symptoms. Second, we reviewed published data on breastmilk composition and thresholds of reactivity in CMA to estimate the probability that cow's milk protein in human breastmilk can trigger symptoms in infants with CMA. We also documented the level of commercial involvement in CMA guidelines.FINDINGS We reviewed 9 CMA guidelines published from 2012 to 2019. Seven suggest considering CMA as a cause of common infant symptoms. Seven recommend strict maternal cow's milk exclusion for managing common symptoms in breastfed infants. We found CMA proven by food challenge affects approximately 1% of infants, while troublesome crying, vomiting, or rashes are each reported in 15% to 20% of infants. We found clinical trials do not provide consistent support for using maternal or infant cow's milk exclusion to manage common symptoms in infants without proven CMA. We estimated that for more than 99% infants with proven CMA, the breastmilk of a cow's milk-consuming woman contains insufficient milk allergen ...

BACKGROUND AND OBJECTIVE: Evidence from randomized controlled trials in early infancy suggest that prenatal supplementation with Ω-3 (n-3) long-chain polyunsaturated fatty acids (LCPUFA) reduces the incidence of allergic disease characterized by an immunoglobulin E (IgE) response. We aimed to determine whether protective effects were evident in the 6-year-old offspring of women supplemented with n-3 rich fish oil during pregnancy.