It is clear that at least some maternally ingested food allergens
pass into breast milk.(1) It is somewhat controversial whether their
presence can sensitize a child to become allergic to the food,(2;3) but it
is clear that for some children who are allergic, these allergenic
proteins can elicit disease manifestations such as skin rashes and
gastrointestinal symptoms.(4) Elimination of the causal food from the
maternal diet can therefore resolve the clinical disease in most
circumstances and would be the preferred therapy.
I thank Ms. Krenz for her comments regarding the importance of
breastfeeding and I certainly agree. There are many reasons that
breastfeeding is encouraged, and even from the standpoint of allergy
prevention and management, breast milk is clearly the preferred source of
nutrition for infants.(3;4)
The discussion about dietary protein-induced proctitis to which Ms.
Krenz refers indicates that maternal dietary restriction of cow’s milk,
and sometimes other proteins, usually results in resolution of rectal
bleeding.(5) The statement that she quotes was meant, in context, to
indicate that if such dietary manipulation was tried but bleeding
continued without being severe and without impacting health, then, indeed,
breast feeding could potentially be continued anyway. That is, there are
no data saying that continued bleeding is intrinsically dangerous in this
setting. Overall then, I meant to impart that continuation of breast
feeding was an important goal and may be possible even if some bleeding
continued in an otherwise healthy infant.
However, even with physician support to ignore bloody stools, it may
not be likely that parents would feel comfortable with seeing frequent,
bloody stools and would seek some intervention by going on extreme diets
or opting for an hypoallergenic formula. Sometimes dietary avoidance
becomes nutritionally problematic for the mother as well. It is in these
situations, and for diagnostic confirmation in the face of failed maternal
dietary elimination trials, that a formula trial may be considered as
discussed in the article. Sometimes a successful trial of a formula may
result in concluding that breastfeeding can be resumed (but that
additional maternal dietary manipulation is needed and worth pursuing).
It is certainly important to discuss any interventions with the
family regarding risks and benefits, particularly when altering the diet
or adding/substituting a formula. However, the nutritional needs and
medical condition of the mother and child should also be kept in mind
together as sometimes severe symptoms, as indicated by Ms. Krenz, may
require discontinuation of breast milk.(4)
Scott Sicherer, MD
Associate Professor of Pediatrics
Jaffe Food Allergy Institute
Mount Sinai School of Medicine
References
(1) Vadas P, Wai Y, Burks W, Perelman B. Detection of peanut
allergens in breast milk of lactating women. JAMA 2001; 285(13):1746-8.
(2) Committee on Nutrition. American Academy of Pediatrics.
Hypoallergenic infant formulas. Pediatrics 2000;106: 346-9.
(3) Zeiger RS. Food allergen avoidance in the prevention of food
allergy in infants and children. Pediatrics 2003; 111(6 Pt 3):1662-71.
(4) Isolauri E, Tahvanainen A, Peltola T, Arvola T. Breast-feeding
of allergic infants [see comments]. J Pediatr 1999; 134(1):27-32.
(5) Sicherer SH. Clinical aspects of gastrointestinal food allergy
in childhood. Pediatrics 2003; 111(6 Pt 3):1609-16.
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