Breastfeeding and infant food allergy prevention: ‘Let the mamas eat’

LOUISVILLE, Ky. — Breastfeeding moms should be encouraged to eat from all food groups and not to exclude food allergens, according to a speaker at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

Although there are not definitive data showing breastfeeding reduces food allergy incidence in infants, there are still benefits to mother and baby, including a reduced risk for certain cancers, postpartum hemorrhage, hypertension and type 2 diabetes in the mother, and lowered risk for sudden infant death syndrome, childhood obesity and gastrointestinal infections in the child.

“We all can agree that breastfeeding is very nutritionally adequate for infants, and it’s beneficial for both mother and child,” Jamie L. Kabourek, MS, RD, registered dietitian and resource manager for the Food Allergy Research and Resource Program at University of Nebraska at Lincoln, said during her presentation. “Environmentally, also, it helps reduce waste and pollution. It’s a renewable resource, and it’s free.”

Breastfeeding and food allergies

Guidance from the American Association of Pediatrics recommends exclusive breastfeeding for the first 6 months of life, at which point complementary foods can be introduced, and breastfeeding can continue through age 1 or 2 years.

When it comes to diet and breastfeeding, in general, guidelines from medical societies do not recommend avoiding allergens in pregnancy or while breastfeeding, Kabourek said, adding that she likes the European Academy of Allergy & Clinical Immunology guidance in particular.

“It’s really short and succinct and says restricting consumption of potential allergenic foods during pregnancy or lactation in order to prevent food allergy is not warranted. Don’t do it,” she said.

Still, there are limited data on the impact of maternal diet during pregnancy and breastfeeding in allergy prevention, Kabourek said, although it is generally recommended to have a diet that includes a variety of foods and allergen diversity.

Kabourek referred to recently published data from Carina Venter, PhD, RD, and colleagues, who created a maternal diet index that predicts the development of childhood allergic diseases. Specifically, women who followed a diet high in fruits, vegetables and yogurt with reduced intake of fruit juice and fried and low-fiber foods had infants at lower risk for allergic diseases.

“If you’ve ever heard Carina talk, she oftentimes says, ‘Let’s let the babies eat,’” Kabourek said. “But I want to say, let the mamas eat too. We really want to try to emphasize the importance of a healthy diet in all aspects of pregnancy and lactating.”

On the flip side, if breastfeeding mothers are concerned their infant might be having a reaction to something in the breastmilk, they should be advised to keep a food journal to track what they have eaten, the baby’s symptoms, and how long those symptoms occur after feeding.

“That helps the family member identify the foods and also it helps the health professional to tease out what might be causing some problems,” Kabourek said.

There are situations when mothers have to withhold foods from their diets due to adverse events in their infants, Kabourek added.

“If they’re having IgE symptoms, generally they’re cutaneous and gastrointestinal over respiratory,” she said. “The symptoms may be delayed, but usually they also are GI manifested. Some culprit foods can be cow’s milk, egg, peanuts, nuts and fish.”

Dietary management requires much more than eliminating food triggers, Kabourek said, adding that only one to two foods should be eliminated at a time and that they should be replaced with something of comparable nutrient makeup.

“We have to tell them to be strict with their elimination,” she said. “That’s where education comes in — label reading and offering substitutions of what they can eat instead of emphasizing what they can’t eat.”

About one-third of severe eczema in infants may be attributable to food allergy, especially if it is early onset, according to Kabourek.

“I don’t think there is anything wrong with eliminating for 2 to 4 weeks ... but you also have to enforce that they have to reintroduce and be ready to take action if an IgE reaction happens,” she said.

Other diet recommendations

Even though clinicians may not be able to specifically recommend diets during pregnancy to prevent food allergies in their infants, there are still general dietary patterns that can be recommended to promote overall health, Kabourek said.

“I think we’re missing part of the boat when we’re [talking to] pregnant moms,” she said. “There are other things they probably can do and we need to focus on their healthy diet and exactly what that healthy diet is. When they’re pregnant and sitting in front of you, there’s no harm in telling them to eat fresh fruits and vegetables in their whole form, not juices, and that refined grains are not good for you.”

Breastfeeding women also should be counseled to increase their caloric intake by 300 to 500 calories a day, and to take a supplement that includes iodine, choline, folate, selenium and zinc.

There are not enough data to support recommending specific prebiotics or probiotics, because it has been hard to pinpoint which bacterial strain might be most beneficial, Kabourek said. However, she added that these can be incorporated naturally into one’s diet by eating certain foods, such as yogurt, kombucha, sauerkraut, kefir, miso and tempeh.

DHA and EHA are also important to incorporate, especially during the third trimester of pregnancy, as they help support central nervous system and neurodevelopment, according to Kabourek. They can be found in fatty fish, such as salmon, or flaxseed.

Offering support

Clinicians also should be prepared to support women who are breastfeeding, as it can be complex, and each breastfeeding journey is different, Kabourek said, adding that survey data show women are most vulnerable to quitting within the first 4 weeks.

“The women surveyed identified milk supply problems with their breasts, either developing mastitis or plugged ducts, problems with the infant’s latch or suckle and postpartum depression,” she said. “This is the very time frame that we need to focus in on to help her be successful.”

Overall, it is important to offer patient-centered guidance and identify a family’s desires when it comes to infant feeding, Kabourek said.

“There’s a balancing point between reducing the medicalization of infant feeding, and letting the families have the fun, discovery and joy that feeding an infant gives, because it’s one of the most rewarding experiences,” she said.

References:

• Halken S, et al. Pediatr Allergy Immunol. 2021;doi:10.1111/pai.13496.
• Venter C, et al. J Allergy Clin Immunol Pract. 2022;doi:10.1016/j.jaip.2022.09.009.