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October 21, 2019

Cow’s Milk and Vitamin D Supplementation in Infants—Timing Is Everything

Author Affiliations
  • 1Division of Asthma, Allergy, and Lung Biology, Department of Paediatric Allergy, King’s College London, Guy’s and St Thomas’ NHS (National Health Service) Foundation Trust, London, United Kingdom
  • 2Institute of Allergy, Department of Pediatrics, Immunology and Pediatric Pulmonology, Sackler School of Medicine, Tel Aviv University, Yitzhak Shamir Medical Center, Zerifin, Israel
  • 3Sean N. Parker Center for Allergy and Asthma Research, Stanford University, Stanford, California
  • 4Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
  • 5Division of Allergy, Immunology and Rheumatology, Stanford University, Stanford, California
JAMA Pediatr. 2019;173(12):1129-1130. doi:10.1001/jamapediatrics.2019.3560

In this issue of JAMA Pediatrics, Urashima and colleagues1 ask whether very early (within 3 days of birth) exposure to cow’s milk formula (CMF) (a common practice in Japan) and vitamin D supplementation (uncommon in Japan) lowers or increases the risk of developing food allergy (as determined by cow’s milk–specific IgE [CM-IgE] sensitization at 5 months and 2 years of age) in infants at risk of atopy (risk was defined as having ≥1 of the father, mother, and/or siblings with current and/or past atopic diseases [eg, asthma]). In recent years, the approach for primary prevention of food allergy has changed dramatically. Earlier recommendations to delay the introduction of allergenic foods to 1 to 3 years of age have now been replaced by newer recommendations to introduce allergenic foods such as peanut and egg at 4 to 6 months of age, after a period of exclusive breastfeeding (EBF).2 The World Health Organization and the European Academy of Allergy and Clinical Immunology (EEACI) recommend EBF for a minimum of 6 months and 4 months, respectively.3 However, whether introduction of all typically allergic foods before 4 to 6 months can decrease risk of allergy is unclear. In the case of CM, this issue is of special importance because supplementation or replacement with formula, even in the first days of life, is not infrequent. Partially or extensively hydrolyzed formulas have been developed to reduce the allergenicity of CM. There is currently a lack of consensus among national allergy societies with respect to recommendations for the use of hypoallergenic formula for the prevention of food allergy in infants who are unable to EBF. Although the EAACI3 and American Academy of Allergy, Asthma and Immunology (AAAI) currently recommend the use of hypoallergenic formulas in infants at high risk of allergy, the Australian Society of Clinical Immunology and Allergy does not. The EAACI and the AAAI are likely to reconsider their guidelines because results of more recent studies have been contradictory. At the current time, insufficient evidence suggests that hydrolyzed formulas might decrease risk of developing food allergy.4

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