Allergic Rhinitis and its Impact on Asthma - ARIA

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ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA GUIDELINES ● 2010 – V. 9/8/2010 The relation between exclusive breastfeeding <strong>and</strong> the development of allergy or asthma needs further elucidation. However, it is unlikely to influence this recommendation. What others are saying Paediatric <strong>and</strong> obstetrical professional societies recommend breastfeeding for all infants unless there are contraindications (58-61), because of reduced risk of infections observed both in developing <strong>and</strong> in developed counties, lower risk of other diseases suggested in many studies, <strong>and</strong> because of maternal health benef<strong>its</strong>. Recommendation We suggest exclusive breastfeeding for at least the first three months for all infants irrespective of their family history of atopy (conditional recommendation | low quality evidence). Values <strong>and</strong> preferences: This recommendation places a relatively high value on the prevention of allergy <strong>and</strong> asthma, <strong>and</strong> a relatively low value on challenges or burden of breastfeeding in certain situations. Remarks: The evidence, that exclusive breastfeeding for at least the first three months reduces the risk of allergy or asthma, is not convincing <strong>and</strong> the recommendation to exclusively breastfeed is conditional. This recommendation applies to situations in which other reasons do not suggest harm from breastfeeding (e.g. classic galactosemia, active untreated tuberculosis or human immunodeficiency virus infection in the mother, antimetabolites, chemotherapeutic agents or radioactive isotopes used in the mother until they clear from the milk, <strong>and</strong> bacterial or viral infection of a breast). Question 2 Should antigen avoidance diet be used in pregnant or breastfeeding women to prevent development of allergy in children? Summary of findings One systematic review reporting on 4 studies assessed maternal dietary antigen avoidance during pregnancy <strong>and</strong>/or lactation for preventing or treating atopic disease in the child (62) (see accompanying evidence profile). Benef<strong>its</strong> Results of available trials suggest that it is unlikely that antigen avoidance diet prevents development of allergy or asthma, although the results are inconsistent, very imprecise <strong>and</strong> the follow-up was limited to the first 18 months of life. Harms There is evidence of very low quality that antigen avoidance diet may increase the risk of preterm birth. Conclusions <strong>and</strong> research needs PAGE 30 OF 153
ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA GUIDELINES ● 2010 – V. 9/8/2010 Any clinical benefit of antigen avoidance diet in pregnant or breastfeeding women to prevent development of allergy in children is very uncertain. Future research, if done, may have an important impact on this recommendation. Recommendation For pregnant or breastfeeding women, we suggest no antigen avoidance diet to prevent development of allergy in children (conditional recommendation | very low quality evidence). Underlying values <strong>and</strong> preferences: This recommendation places a relatively high value on adequate nourishment of mothers <strong>and</strong> children, <strong>and</strong> a relatively low value on very uncertain effects on the prevention of allergy <strong>and</strong> asthma in this setting. Question 3 Should children <strong>and</strong> pregnant women avoid environmental tobacco smoke (i.e. passive smoking) to reduce the risk of developing allergy, wheezing, or asthma in children? Summary of findings A series of systematic reviews of observational studies evaluated the relation between environmental tobacco smoke (ETS, secondh<strong>and</strong> smoke or passive smoking) exposure <strong>and</strong> respiratory health in children. These systematic reviews generally reported an increased risk of asthma, wheeze, <strong>and</strong> chronic cough in children in families where either parent smoked (63-68). A link between environmental tobacco smoke exposure <strong>and</strong> development of allergy was not found (69). We identified two additional more recent reports of studies that showed increased risk of wheezing in children exposed to parental smoking (70, 71). A World Health Organization Report on Tobacco Smoke <strong>and</strong> Child Health (72) found that ETS has adverse effects during gestation <strong>and</strong> has definite effects after birth including increased risks of lower respiratory tract infection during infancy <strong>and</strong> chronic respiratory symptoms in school-aged children. ETS increases the severity <strong>and</strong> frequency of symptoms in children with asthma, is causally associated with increased risk of acute <strong>and</strong> chronic middle ear disease <strong>and</strong> is a cause of small reductions in average birth weight (exposure of non-smoking women during pregnancy). Parental smoking is also associated with learning difficulties, behavioural problems, <strong>and</strong> language impairment. There is evidence that tobacco smoke exposure causes non-allergic wheezing in early life, but whether it does cause asthma is less clear. In addition, evidence does not support a role of parental smoking during the perinatal period for allergic sensitization. Nevertheless, ETS exposure causes exacerbations of symptoms in children with asthma. Although these increased risks are modest, these are common health problems around the world. Thus small increases in risk translate into a substantial absolute burden of disease for children arising from exposure to ETS. The most recent report from Surgeon General on respiratory Effects in Children from Exposure to Secondh<strong>and</strong> Smoke (68) found sufficient evidence to infer a causal relationship between parental smoking <strong>and</strong> cough, phlegm production, wheeze, <strong>and</strong> breathlessness as well as ever having asthma among children of school age. The evidence was judged sufficient to infer a causal relationship between ETS exposure from parental smoking <strong>and</strong> the onset of wheeze in early childhood. It was PAGE 31 OF 153
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Allergic Rhinitis and its Impact on Asthma - ARIA

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