牛奶蛋白过敏的婴儿的喂养

牛奶蛋白过敏的婴儿的喂养 牛奶蛋白过敏的婴儿的喂养(欧/澳洲喂养建议) 对于确诊的牛奶蛋白过敏的婴儿，这是欧洲儿科肠胃病学、肝脏病学和营养学会的喂养建议: 母乳喂养的婴儿 母亲应该被鼓励继续母乳喂养，但是哺乳的妈妈需要忌口所有的奶制品(包括含有乳清蛋白、酪蛋白成分的食物)。 如果宝宝在服用任何母乳之外的补充食物或者药物，需要是完全不含牛奶蛋白的。 如果发生过立即出现反应的过敏，妈妈的忌口只需要持续3到6天。如果可能有延迟的过敏反应(过敏导致了持续的后果，如直肠结肠炎)，那么妈妈的忌口需要持续14天。 如果妈妈忌口还是没有任何帮助，那么可能牛奶蛋白过敏的诊断是错误的，可能是别的什么导致了过敏，那么孩子状况需要进一步的评估和诊断。如果妈妈忌口后孩子症状消失或好转，那么妈妈可以重新恢复她的饮食(可以继续吃奶制品)。可能又会有症状出现，妈妈希望继续在保持无牛奶蛋白的饮食下母乳喂养，那么妈妈需要服用钙补充剂(如果不吃奶制品，妈妈的钙摄入会不足。可以每天分多次服用总剂量达1000毫克/每天的钙剂)。忌口情况下的饮食请咨询营养师，以满足妈妈的营养需求。 在一些母乳宝宝中，牛奶蛋白以外的一些蛋白质如蛋、大豆(soy)，也可能引起过敏反应。如果发现妈妈在哺乳期间，吃鸡蛋、大豆(soy)或者别的食物，会引起宝宝过敏，妈妈应该被鼓励继续母乳喂养，同时避免吃这些食物。 如果母乳宝宝有严重的过敏反应(如严重的湿疹或者过敏性结肠炎，同时伴随生长发育问题，和/或 血液蛋白不足 和/或 严重的贫血)，婴儿可能需要用治疗性的配方奶一段时间，从几天到最长两周。尽管没有证据支持，在很多国家 比较常见的操作是，给这些被诊断为严重过敏反应的纯母乳喂养宝宝喝氨基酸配方的奶粉(AAF)。这是为了能在母乳妈妈在把饮食调整为不含牛奶蛋白饮食期间，喂给宝宝以稳定宝宝的状况。在一些妈妈已经忌口了含牛奶蛋白的饮食，仍然反复出现症状的的母乳宝宝身上，母乳妈妈需要进一步地限制饮食，或者断母乳用治疗性的配方奶。 配方奶喂养的婴儿 在没有母乳喂养的婴儿里，任何以牛奶为配方的配方奶和含有牛奶蛋白的辅食，或者其他动物的奶的蛋白质(如山羊奶，绵羊奶)都要严格避免。如果是给母乳喂养的宝宝喂了配方奶导致的症状，婴儿应该回到纯母乳喂养，哺乳妈妈也不需要任何忌口。配方奶喂养的宝宝如果确诊是牛奶蛋白过敏，通常以喂深度水解配的配方奶(extensively hydrolyzed infant formula，又被称为完全水解配方)开始。而对于有极端严重的过敏或者威胁生命的症状的那些婴儿，氨基酸配方或许可以作为首选。对于6个月以上的婴儿如果不能适应有点苦的深度水解配方，或者某些家庭无法负担深度水解奶粉(因为比较贵)，已经建立起对大豆蛋白耐受的婴儿，可考虑大豆配方奶。如果2周后还没有任何好转，那么需要考虑宝宝可能对深度水解配方中还存在的多肽类有过敏反应，特别是在对很多食物都过敏的婴儿身上可能发生这种状况。这时，才考虑尝试氨基酸配方，除非已经排除了牛奶蛋白过敏。 过去有这样的考虑，牛奶蛋白过敏的宝宝可能对乳糖中可能残存的蛋白起反应，常常需要同时避免乳糖和牛奶蛋白。但目前的证据并不支持这种说法，因此同时避免乳糖和牛奶蛋白的做法不再推荐。含有纯的乳糖的深度水解配方已经有了，发现是安全的，而且对牛奶蛋白过敏也有效。这样的深度水解配方可能对于6个月以上的婴儿口味更加好一些。但是，续发行乳糖不耐受可能会发生在那些已经有拉肚子的宝宝身上，如果发生乳糖不耐受拉肚子，需要立即换喝无乳糖的深度水解配方。 澳洲婴儿喂养指南2013的相关建议: 这个指南是非常支持母乳喂养的，关于特殊配方的奶粉: 牛奶配比大豆、山羊奶或者改变了乳糖的配方奶更适合大多数健康的足月产宝宝。为有营养问题的婴儿设计的特殊配方奶的配方奶只应该在有医学诊断出的症状的时候，在儿科医生的指导下使用。 因为轻微的湿疹，过敏，或者婴儿或妈妈的不开心(distress)而换奶的种类(比如普通配方换至水解配方)，通常没有任何好处。 澳洲婴儿喂养指南给爸爸妈妈的建议是: • 用以牛奶为基础的婴儿配方奶直到12个月(澳洲所有的婴儿配方奶都是强化了铁的) • 如果婴儿因为医学的、文化的或者信仰的原因，不能喝牛奶配方的配方奶，特殊配方的奶粉需要在医生的指导下使用。 预防有家族过敏史的婴儿的过敏, 水解配方 澳洲皇家医学院(RAcP)建议，给没有母乳喂养的，已经证明有牛奶过敏或者牛奶蛋白过敏的婴儿，用深度水解配方(extensively hydrolysed infant formula)喂养。 关于大豆配方的配方奶(Soy-based formulas) 澳洲皇家医学院(RAcP)对于大豆配方配方奶的建议: • 12个月以内的，没有母乳喂养的婴儿应该喂婴儿配方奶，而不是喂给更大的孩子和成人喝的豆奶或者市面上的鲜奶。 • 早产儿不应该喂大豆配方的配方奶。 • 对于有甲状腺功能紊乱的婴儿，应该考虑到大豆配方奶对甲状腺素替换治疗(thyroxin replacement therapy)的干扰 。 • 关于大豆配方有一些特殊的考虑——大豆异黄酮对婴儿神经内分泌的可能的生理上的影响。并没有临床的或者科学的证据支持这些成分是有害的，但是，也没有长期的研究总结大豆配方奶对婴儿的安全性。用大豆配方奶来控制半乳糖血(galactosaemia)是合适的。对于那些因为文化或者信仰原因不能饮用奶配方的产品的婴儿，给他们喂大豆配方也可能是适宜的。 山羊配方奶 比起牛奶配方，只有很少的研究评估了山羊奶配方奶的安全性和功效。山羊奶不具备任何预防或者治疗过敏性疾病的功效。很多对牛奶蛋白过敏的婴儿也会对山羊奶和大豆饮品过敏。用山羊配方奶是不建议的。 氨基酸配方奶 氨基酸配方奶或基本营养素配方奶是由营养素组成的，包括单独的氨基酸。氨基酸配方奶在预防过敏性疾病方面研究不足。(这和美国儿科学会的一致) 含有益生菌或者益生元的配方奶 对于含有益生菌或者益生元的配方奶预防过敏疾病的结果不一。两篇cochrane综述和一篇欧洲儿科肠胃病学学会，肝脏学和营养协会的综述做出这样的结论:没有足够的证据支持来建议用含有益生菌或者益生元的配方奶。 母亲的饮食限制 没有任何证据明孕期或者哺乳期或者婴儿期不要提供特定的食物，在预防过敏方面有任何作用。且不再被建议。 如何降低有家族过敏史的婴儿的过敏风险: 1. 孕期不抽烟，且在孕期和孩子出生后完全无烟的环境。 2. 不建议孕期忌口任何特定的潜在食物过敏原，这对于儿童期的过敏没有预防 作用。 3. 如果因为某种原因，停止了母乳喂养，用特殊配方的配方奶对预防过敏没有 任何优势，除非是在医生的指导下的使用。 4. 大豆配方奶不能预防或减少发生过敏的风险，也不是适宜的婴儿配方奶。 给家长的建议 大豆或山羊配方奶并不是适合对牛奶配方过敏的婴儿，除非是在医生的指导 下使用。 在孕期、哺乳期或者婴儿期避免任何特定的食物或者食物过敏原，并不能预 防过敏的发生。(这和美国儿科学会最新的建议一致) Advice for parents ESPGHAN GI Committee Practical Guidelines Breast-fed Infants Mothers should be encouraged to continue breast-feeding while avoiding all milk and milk products from their own diet. This usually requires qualified dietary counseling to completely exclude hidden sources of CMP. If the infant receives any complementary feedings or drugs, these must be free of CMP. If the history suggests an immediate reaction, then the maternal elimination diet needs to be maintained for only 3 to 6 days. If delayed reactions are suspected (eg, allergic proctocolitis), then the diet should be continued for up to 14 days. If there is no improvement, then it is likely that diagnoses other than CMPA are the cause of the symptoms and the child should be further evaluated. If symptoms improve, then a reintroduction of CMP into the mother’s diet should then be performed. Should this challenge prove positive and the mother wishes to continue breast-feeding while maintaining a CMP-free diet, she should be given calcium supplements (eg, 1000 mg/day spread across the day) and dietetic counseling to ensure her nutritional needs (44). In some breast-fed infants, proteins other than CMP (eg, soy, egg) may cause allergic reactions (45). If there is a valuable benefit of maternal elimination diet on the well-being of the infant, then the mother should be encouraged and supported to continue breast-feeding while eliminating the causative foods from her own diet. In breast-fed infants with severe symptoms (eg, severe atopic eczema or allergic (entero) colitis complicated by growth faltering and/or hypoproteinemia and/or severe anemia), the infant may be fed with a therapeutic formula for a period of from several days to a maximum of 2 weeks (45). Even if not evidence based, it is common practice in many countries to use AAF for diagnostic elimination in these extremely sick exclusively breast-fed infants. This approach is to stabilize the child’ s condition while the mother expresses breast milk in transition to her CMP-free diet. In cases in which symptoms recur on breast milk despite a strict CMP-free diet in the mother, further elimination of other highly allergenic foods from the mother’s diet or weaning from breast milk to a therapeutic formula is recommended (46,47). Non–breast-fed Infants In non–breast-fed infants, cow’s-milk–based formula and supplementary foods containing CMP or other unmodified animal milk proteins (eg, goat’ s milk, sheep’s milk) should be strictly avoided (48,49). If the first feeds with cow’s-milk – based formula in a breast-fed infant cause symptoms, the infant should return to exclusive breast-feeding without any elimination in the maternal diet. An elimination diet in formula-fed infants usually starts with an extensively hydrolyzed infant formula (eHF) with proven efficacy in infants with CMPA (9,48). In infants with extremely severe or life-threatening symptoms, an AAF may be considered as the first choice. Soy protein – based formula may be an option in infants older than 6 months who do not accept the bitter taste of an eHF, or in cases in which the higher cost of an eHF is a limiting factor, provided that the tolerance to soy protein has been established. If there is no improvement within 2 weeks, then an allergic reaction to the remaining peptides in the eHF must be considered, particularly in infants with sensitization against multiple foods (43,42). In these cases, an AAF should be tried before CMPA is ruled out as cause of the symptoms. Previous concerns that infants with CMPA would react to residual protein traces in lactose have often resulted in complete avoidance of both lactose and CMP. Adverse reactions to lactose in CMPA are not supported in the literature, and complete avoidance of lactose in CMPA is no longer warranted. eHFs containing purified lactose are now available and have been found safe and effective in the treatment of CMPA (50). These formulae may also be more palatable for infants older than 6 months. It is, however, possible for secondary lactose intolerance to coexist in infants who have enteropathy with diarrhea, and therefore a lactose-free eHF will be required initially in these cases. NHMRC: Infant Feeding Guidelines Information for health workers Special infant formulas cow’s milk-based formula is suitable for most healthy full-term infants and is recommended over formulas made from soybeans, goat’s milk or modified lactose formula. special formula designed for infants with nutritional problems should be used only in the case of medically diagnosed conditions on the advice of a paediatrician (see section 8.5.2). changing the type of formula because of minor rashes, irritability or infant or parent distress is usually of no benefit. Advice to parents • Use cow’s milk-based infant formulas until 12 months of age (all infant formulas available in Australia are iron-fortified). • special formulas may be used under medical supervision for infants who cannot take cow’s milk-based products for specific medical, cultural or religious reasons. 8.5.1 Preventing allergies in infants with a family history Allergies and food reactions in infants and children are common and may be associated with a variety of foods including adapted cow’s milk formula. Parents often consider using special infant formulas for preventing or treating allergic disorders. different infant formulas have been considered for this purpose, including amino acid-based formula, hydrolysed formula, soy formula and milk from other animal species. However the evidence is mixed and routine use of special formulas for preventing allergy is not recommended. An Australian expert panel has made recommendations on the use of soy, extensively hydrolysed and amino acid formulas for treating cow’s milk protein allergy.480 Hydrolysed formula Hydrolysed formula, which is cow’s milk-based formula that has been processed to break down most of the proteins into smaller particles, may modify the development of allergic disease.76 For infants with a strong history of atopy, there is limited evidence that hydrolysed formula, in comparison with cow’s milk formula, reduces infant and childhood allergy.481 most studies on the use of hydrolysed formulas have involved infants at high risk of atopy rather than the general population and benefits have been modest. Additional randomised studies are needed among infants from families with low risk of atopy. there is no evidence that partially hydrolysed infant formula prevents allergic disease when used for supplementary feeds in hospitals, and widespread use for this purpose may undermine breastfeeding. the Royal Australasian college of Physicians (RAcP) recommends the use of extensively hydrolysed infant formula in infants with proven cow’s milk allergy or cow’s milk protein intolerance who are not breastfed.482 Soy-based formulas soy formula has not been shown to be effective in preventing the development of atopy in ‘at-risk’ children, and may worsen atopic illness with prolonged use.482 A cochrane review concluded that feeding with soy formula should not be recommended for preventing atopy in infants at high risk of developing allergy.483 Further research may be warranted to determine the role of soy formulas for preventing allergy or food intolerance in infants who are unable to be breastfed, who have a strong family history of allergy or cow’s milk protein intolerance. the RAcP policy for the use of soy formula in infants recommends that:482 • infants under 12 months who are not breastfed should be fed an infant formula, not a soy drink or dairy-based milk marketed for older children or adult consumption • soy-based infant formula should not be used for preterm infants • the possible interaction of soy-based formula with thyroxin replacement therapy should be considered for children with thyroid disorders. A number of concerns have been raised about soy-based infant formulas, on the basis of possible physiological effects of isoflavone compounds on the infant’ s developing neuroendocrine system. there is no clear clinical or scientific evidence to support the position that these compounds are harmful, although no long-term studies have conclusively documented the product’s safety in infants. It is appropriate to use soy infant formula in the management of galactosaemia.482,484 Its use may also be appropriate for infants who cannot consume dairy-based products for cultural or religious reasons.484 • Goat’s milk formula compared to cow’s milk formulas, there have been fewer studies evaluating the safety and efficacy of goat’s milk formulas. goat’s milk is not considered to have any role in preventing or treating allergic disease. many infants who are allergic to cow’s milk are also allergic to goat’s milk and soy drinks.483,485 the use of goat’s milk formula is not recommended. • Amino acid-based formula Amino acid-based or elemental formula is “built” from component nutrients including individual amino acids. Its use in preventing atopic disease has not been studied.76 Infant formulas with probiotics or prebiotics the evidence on probiotics or prebiotics in infant formula to prevent atopic disease varies. two cochrane reviews and a review by the european society for Paediatric gastroenterology, Hepatology and nutrition (esPgHAn) committee on nutrition concluded there was insufficient evidence to recommend their use.486-488 Maternal dietary restriction there is no evidence that avoiding any particular foods or food allergens during pregnancy, lactation or infancy provides any benefit in preventing allergy and this is no longer recommended.73 Table 8.6: Minimising the risk of allergy in infants with a family history • Do not smoke during pregnancy and provide a smoke-free environment for your child after birth489 • Dietary elimination of potential allergens during pregnancy is not recommended for preventing childhood allergy • If breastfeeding is discontinued for any reason, there is no advantage in using special formulas, except under medical supervision • Soy-based formulas do not prevent or reduce the risk of developing allergies and are not a suitable alternative to cow’s milk-based formulas Advice to parents: • soy or goat’s milk-based formulas are not suitable alternatives for infants with allergies to cow’s milk-based formulas unless used under medical supervision. • Avoiding any particular foods or food allergens during pregnancy, lactation or infancy does not prevent allergy development. 来源:夏天的陈小舒(公共卫生博士，从事儿童营养与健康研究)