10.1586/ECI.12.80 31 ISSN 1744-666X © 2013 Expert Reviews Ltd www.expert-reviews.com
Perspective
Allergic conditions cause a substantial burden
of illness worldwide both in children and adults
[1,2] . These conditions impact on the individual,
their family and the healthcare system. The
common manifestations of allergic disease shift
with increasing age of the child; in early infancy,
eczema and food allergy are the most common
symptoms, while asthma and allergic rhinitis
become more important as the child ages. There
was a rapid rise in the prevalence of allergic con-
ditions in the later part of the 20th century [3–5] .
While prevalence of childhood asthma appears
to have reached a plateau, or declined in some
countries [1] , it remains a major cause of hospital-
ization and healthcare expenditure. The rates of
allergic rhinitis and eczema in children continue
to increase in many parts of the world [1] , and
there is also evidence that the rate of other sys-
temic allergic conditions, including anaphylaxis
and food allergy, are increasing [6–8] . Despite
active research, the reasons for these shifts in
prevalence of disease remain unclear.
Research in this area aims at identifying
interventions that can prevent children from
developing these conditions in the first place. If
early forms of disease can be prevented, there is
a potential for sustained long-term benefits and
reduced risk of other forms of allergic disease in
later life [9] . Despite substantial research efforts,
there are currently no interventions that have
been clearly demonstrated to prevent children
developing these conditions, although it is known
that early life exposures (during pregnancy and
early infancy) may be critical [10] . The infant
diet, including breast or formula feeding and the
introduction of solid foods, has attracted par-
ticular attention as early life exposures that may
influence allergic disease risk and importantly,
have the potential to be easily modified.
Currently, international expert guidelines
from the USA (American Academy of Pediatrics)
[11] , Europe (European Academy of Allergy
and Clinical Immunology/European Society
for Paediatric Gastroenterology, Hepatology
and Nutrition) [12] and Australia (Australasian
Society of Clinical Immunology and Allergy)
[101] recommend a limited number of inter-
ventions for prevention of allergic disease. All
Adrian J Lowe*
1,2
,
Shyamali C
Dharmage
1,2
,
Katrina J Allen
1,3,4
,
Mimi LK Tang
1,3,4
and
David J Hill
1
1
Murdoch Children’s Research Institute,
Royal Children’s Hospital, Melbourne,
Australia
2
Centre for Molecular, Environmental,
Genetic and Analytic Epidemiology,
School of Population Health,
The University of Melbourne,
Melbourne, Australia
3
Department of Paediatrics, University
of Melbourne, Melbourne, Australia
4
Department of Allergy and
Immunology, Royal Children’s Hospital
*Author for correspondence:
Tel.: +61 3 8344 0878
Fax: +61 3 9349 5815
lowe.adrian@gmail.com
Hydrolyzed formulae are created by using enzymatic processes to break native proteins into smaller
fragments. They may prevent development of allergic diseases by reducing exposure to intact
allergens. Partially hydrolyzed whey formula (pHWF) is particularly promising for allergy prevention,
as it is cheap to manufacture and palatable. Scientific organizations have recommended the use
of hydrolyzed formula in the first 4–6 months of life for the prevention of allergic disease based
on a limited number of trials. Three recent developments challenge these recommendations: our
growing understanding of the importance of allergen exposure for induction of immune tolerance,
recently published evidence that failed to identify a protective effect of pHWF, which the authors
and other experts believe will necessitate updating of systematic reviews, and methodological
limitations of available trials and systematic reviews on which these recommendations are based.
Until more definitive evidence is obtained, the authors recommend continuing to advocate that
‘breast is best’, and caution against overstating the potential for pHWF to prevent allergic disease.
The role of partially hydrolyzed
whey formula for the
prevention of allergic disease:
evidence and gaps
Expert Rev. Clin. Immunol. 9(1), 31–41 (2013)
KEYWORDS:allergicrhinitis•allergyprevention•asthma•conventionalcows’milkformulae•eczema
•infantformulae•partiallyhydrolyzedwheyformula
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