Diet during pregnancy and infancy, and risk of allergic or autoimmune disease: a systematic review and meta-analysis

Background: There is uncertainty about the influence of diet during pregnancy and infancy on a child’s immune development. We assessed whether variations in maternal or infant diet can influence risk of allergic or autoimmune disease. Methods and findings: Two authors selected studies, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess certainty of findings. We searched Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Web of Science, Central Register of Controlled Trials (CENTRAL), and Literatura Latino Americana em Ciências da Saúde (LILACS) between January 1946 and July 2013 for observational studies and until December 2017 for intervention studies that evaluated the relationship between diet during pregnancy, lactation, or the first year of life and future risk of allergic or autoimmune disease. We identified 260 original studies (964,143 participants) of milk feeding, including 1 intervention trial of breastfeeding promotion, and 173 original studies (542,672 participants) of other maternal or infant dietary exposures, including 80 trials of maternal (n = 26), infant (n = 32), or combined (n = 22) interventions. Risk of bias was high in 125 (48%) milk feeding studies and 44 (25%) studies of other dietary exposures. Evidence from 19 intervention trials suggests that oral supplementation with nonpathogenic micro-organisms (probiotics) during late pregnancy and lactation may reduce risk of eczema (Risk Ratio [RR] 0.78; 95% CI 0.68–0.90; I2 = 61%; Absolute Risk Reduction 44 cases per 1,000; 95% CI 20–64), and 6 trials suggest that fish oil supplementation during pregnancy and lactation may reduce risk of allergic sensitisation to egg (RR 0.69, 95% CI 0.53–0.90; I2 = 15%; Absolute Risk Reduction 31 cases per 1,000; 95% CI 10–47). GRADE certainty of these findings was moderate. We found weaker support for the hypotheses that breastfeeding promotion reduces risk of eczema during infancy (1 intervention trial), that longer exclusive breastfeeding is associated with reduced type 1 diabetes mellitus (28 observational studies), and that probiotics reduce risk of allergic sensitisation to cow’s milk (9 intervention trials), where GRADE certainty of findings was low. We did not find that other dietary exposures—including prebiotic supplements, maternal allergenic food avoidance, and vitamin, mineral, fruit, and vegetable intake—influence risk of allergic or autoimmune disease. For many dietary exposures, data were inconclusive or inconsistent, such that we were unable to exclude the possibility of important beneficial or harmful effects. In this comprehensive systematic review, we were not able to include more recent observational studies or verify data via direct contact with authors, and we did not evaluate measures of food diversity during infancy. Conclusions: Our findings support a relationship between maternal diet and risk of immune-mediated diseases in the child. Maternal probiotic and fish oil supplementation may reduce risk of eczema and allergic sensitisation to food, respectively

National clinical practice guidelines for food allergy and anaphylaxis:an international assessment

Background: clinical practice guidelines are important tools to promote evidence-based clinical care, but not all countries have the capacity or infrastructure to develop these in-house. The European Academy of Allergy and Clinical Immunology has recently developed guidelines for the prevention, diagnosis and management of food allergy and the management of anaphylaxis. In order to inform dissemination, adaptation and implementation plans, we sought to identify countries that have/do not have national guidelines for food allergy and anaphylaxis.Methods: two reviewers independently searched PubMed to identify countries with guidelines for food allergy and/or anaphylaxis from the inception of this database to December 2016. This was supplemented with a search of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse in order to identify any additional guidelines that may not have been reported in the peer-reviewed literature. Data were descriptively and narratively synthesized.Results: overall, 5/193 (3%) of countries had at least one guideline for food allergy or anaphylaxis. We found that one (1%) country had a national guideline for the prevention of food allergy, three (2%) countries had a guideline for the diagnosis of food allergy and three (2%) countries had a guideline for the management of food allergy. Three (2%) countries had an anaphylaxis guideline.Conclusions: this study concludes that the overwhelming majority of countries do not have any national clinical practice guidelines for food allergy or anaphylaxis

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

Background: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).Methods: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.Results: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.Conclusion: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding. </p

Sickness absence in a re-employment program as a predictor of labor market attachment among long-term unemployed individuals: A 6-year cohort study in Finland

Objectives We examined whether sickness absence during participation in a state subsidized re-employment program among long-term unemployed people was associated with subsequent labor market attachment. Methods We linked 18 944 long-term unemployed participants (aged 18–60 years) of a six-month subsidized re-employment program in Finland to their records of sickness absence during the program and labor market status after the program. We used the latent class growth model to identify labor market attachment trajectories over a six-year follow-up period and multinomial logistic regression to investigate the association between sickness absence and labor market attachment trajectories. Results We identified four labor market attachment trajectories: "strengthening", (77%), "delayed" (6%), "leavers" (10%), and "non-attached" (7%). Sickness absence was associated with an increased risk of belonging to the leavers and non-attached trajectories. Having >30 days of sickness absence during the six-month re-employment program increased the risk for belonging to the future non-attached trajectory in all age groups, but in particular for those aged 30–44 [odds ratio (OR) 7.35, 95% confidence interval (CI) 4.85–11.14] and 18–29 years (OR 5.38, 95% CI 3.76–7.69). At these ages, having fewer than 30 days sickness absences was also associated with an elevated risk of belonging to the non-attached trajectory, while this risk was lower for those aged 45–60. Conclusions Sickness absence during participation in a subsidized re-employment program increased the risk for poor labor market attachment during the subsequent six years. The risk was particularly high among younger participants with >30 days of sickness absence

Sickness absence in a re-employment program as a predictor of labor market attachment among long-term unemployed individuals: A 6-year cohort study in Finland

Objectives We examined whether sickness absence during participation in a state subsidized re-employment program among long-term unemployed people was associated with subsequent labor market attachment. Methods We linked 18 944 long-term unemployed participants (aged 18–60 years) of a six-month subsidized re-employment program in Finland to their records of sickness absence during the program and labor market status after the program. We used the latent class growth model to identify labor market attachment trajectories over a six-year follow-up period and multinomial logistic regression to investigate the association between sickness absence and labor market attachment trajectories. Results We identified four labor market attachment trajectories: "strengthening", (77%), "delayed" (6%), "leavers" (10%), and "non-attached" (7%). Sickness absence was associated with an increased risk of belonging to the leavers and non-attached trajectories. Having >30 days of sickness absence during the six-month re-employment program increased the risk for belonging to the future non-attached trajectory in all age groups, but in particular for those aged 30–44 [odds ratio (OR) 7.35, 95% confidence interval (CI) 4.85–11.14] and 18–29 years (OR 5.38, 95% CI 3.76–7.69). At these ages, having fewer than 30 days sickness absences was also associated with an elevated risk of belonging to the non-attached trajectory, while this risk was lower for those aged 45–60. Conclusions Sickness absence during participation in a subsidized re-employment program increased the risk for poor labor market attachment during the subsequent six years. The risk was particularly high among younger participants with >30 days of sickness absence