What medicine is good for allergies while breastfeeding

Food allergies can own rapid-onset (from minutes up to 2 hours), delayed-onset (up to 48 hours or even 1 week), or combinations of both, depending on the mechanisms involved. The difference depends on the types of white blood cells involved. B cells, a subset of white blood cells, rapidly synthesize and secrete immunoglobulin E (IgE), a class of antibody which bind to antigens, i.e., the foreign proteins. Thus, immediate reactions are described as IgE-mediated.

The delayed reactions involve non-IgE-mediated immune mechanisms initiated by B cells, T cells, and other white blood cells. Unlike with IgE reactions, there are no specific biomarker molecules circulating in the blood, and so, confirmation is by removing the suspect food from the diet and see if the symptoms resolve.[18]

IgE-mediated symptoms include: rash, hives, itching of the mouth, lips, tongue, throat, eyes, skin, or other areas, swelling of the lips, tongue, eyelids, or the whole face, difficulty swallowing, runny or congested nose, hoarse voice, wheezing, shortness of breath, diarrhea, abdominal pain, lightheadedness, fainting, nausea and vomiting.

Symptoms of allergies vary from person to person and may also vary from incident to incident.[19] Serious harm regarding allergies can start when the respiratory tract or blood circulation is affected. The previous can be indicated by wheezing, a blocked airway and cyanosis, the latter by feeble pulse, pale skin, and fainting.

What medicine is excellent for allergies while breastfeeding

When these symptoms happen, the allergic reaction is called anaphylaxis.[19] Anaphylaxis occurs when IgE antibodies are involved, and areas of the body that are not in direct contact with the food become affected and show severe symptoms.[19][20] Untreated, this can proceed to vasodilation, a low blood pressure situation called anaphylactic shock, and extremely rarely, death.[6][20]

For milk allergy, non-IgE-mediated responses are more common than IgE-mediated.[21] The presence of certain symptoms, such as angioedema or atopic eczema, is more likely related to IgE-mediated allergies, whereas non-IgE-mediated reactions manifest as gastrointestinal symptoms, without skin or respiratory symptoms.[18][22] Within non-IgE cow’s milk allergy, clinicians distinguish among food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP) and food protein-induced enteropathy (FPE).

Common trigger foods for every are cow’s milk and soy foods (including soy baby formula).[22][23] FPIAP is considered to be at the milder finish of the spectrum, and is characterized by intermittent bloody stools. FPE is identified by chronic diarrhea which will resolve when the offending food is removed from the infant’s diet. FPIES can be severe, characterized by persistent vomiting, 1 to 4 hours after an allergen-containing food is ingested, to the point of lethargy.

Watery and sometimes bloody diarrhea can develop 5 to 10 hours after the triggering meal, to the point of dehydration and low blood pressure. Infants reacting to cow’s milk may also react to soy formula, and vice versa.[23][24] International consensus guidelines own been established for the diagnosis and treatment of FPIES.[24]


Mechanisms

Conditions caused by food allergies are classified into three groups according to the mechanism of the allergic response:[25]

  • IgE-mediated (classic) – the most common type, manifesting as acute changes that happen shortly after eating, and may progress to anaphylaxis
  • Non-IgE mediated – characterized by an immune response not involving IgE; may happen hours to days after eating, complicating the diagnosis
  • IgE- and non-IgE-mediated – a hybrid of the above two types

Allergic reactions are hyperactive responses of the immune system to generally innocuous substances, such as proteins in the foods we eat.

Some proteins trigger allergic reactions while others do not. One theory is resistance to digestion, the thinking being that when largely intact proteins reach the little intestine the white blood cells involved in immune reactions will be activated.[26] The heat of cooking structurally degrades protein molecules, potentially making them less allergenic.[27] Allergic responses can be divided into two phases: an acute response that occurs immediately after exposure to an allergen, which can then either subside or progress into a «late-phase reaction,» prolonging the symptoms of a response and resulting in more tissue damage.[28][29]

In the early stages of acute allergic reaction, lymphocytes previously sensitized to a specific protein or protein part react by quickly producing a specific type of antibody known as secreted IgE (sIgE), which circulates in the blood and binds to IgE-specific receptors on the surface of other kinds of immune cells called mast cells and basophils.

Both of these are involved in the acute inflammatory response.[28] Activated mast cells and basophils undergo a process called degranulation, during which they release histamine and other inflammatory chemical mediators (cytokines, interleukins, leukotrienes, and prostaglandins) into the surrounding tissue causing several systemic effects, such as vasodilation, mucous secretion, nerve stimulation, and smooth muscle contraction. This results in runny nose, itchiness, shortness of breath, and potentially anaphylaxis. Depending on the individual, the allergen, and the mode of introduction, the symptoms can be system-wide (classical anaphylaxis), or localized to specific body systems; asthma is localized to the respiratory system, while eczema is localized to the skin.[28]

After the chemical mediators of the acute response subside, late-phase responses can often happen due to the migration of other white blood cells such as neutrophils, lymphocytes, eosinophils, and macrophages to the initial reaction sites.

This is generally seen 2–24 hours after the original reaction.[29] Cytokines from mast cells may also frolic a role in the persistence of long-term effects. Late-phase responses seen in asthma are slightly diverse from those seen in other allergic responses, although they are still caused by release of mediators from eosinophils.[30]

Six major allergenic proteins from cow’s milk own been identified: αs1-, αs2-, β-, and κ-casein from casein proteins and α-lactalbumin and β-lactoglobulin from whey proteins. There is some cross-reactivity with soy protein, particularly in non-IgE mediated allergy.

Heat can reduce allergenic potential, so dairy ingredients in baked goods may be less likely to trigger a reaction than milk or cheese. For milk allergy, non-IgE-mediated responses are more common than IgE-mediated. The previous can manifest as atopic dermatitis and gastrointestinal symptoms, especially in infants and young children. Some will display both, so that a kid could react to an oral food challenge with respiratory symptoms and hives (skin rash), followed a day or two later with a flare up of atopic dermatitis and gastrointestinal symptoms, including chronic diarrhea, blood in the stools, gastroesophageal reflux disease (GERD), constipation, chronic vomiting and colic.[2]

Allergic reactions are hyperactive responses of the immune system to generally innocuous substances, such as proteins in the foods we eat.

Some proteins trigger allergic reactions while others do not. One theory is resistance to digestion, the thinking being that when largely intact proteins reach the little intestine the white blood cells involved in immune reactions will be activated.[26] The heat of cooking structurally degrades protein molecules, potentially making them less allergenic.[27] Allergic responses can be divided into two phases: an acute response that occurs immediately after exposure to an allergen, which can then either subside or progress into a «late-phase reaction,» prolonging the symptoms of a response and resulting in more tissue damage.[28][29]

In the early stages of acute allergic reaction, lymphocytes previously sensitized to a specific protein or protein part react by quickly producing a specific type of antibody known as secreted IgE (sIgE), which circulates in the blood and binds to IgE-specific receptors on the surface of other kinds of immune cells called mast cells and basophils.

Both of these are involved in the acute inflammatory response.[28] Activated mast cells and basophils undergo a process called degranulation, during which they release histamine and other inflammatory chemical mediators (cytokines, interleukins, leukotrienes, and prostaglandins) into the surrounding tissue causing several systemic effects, such as vasodilation, mucous secretion, nerve stimulation, and smooth muscle contraction. This results in runny nose, itchiness, shortness of breath, and potentially anaphylaxis. Depending on the individual, the allergen, and the mode of introduction, the symptoms can be system-wide (classical anaphylaxis), or localized to specific body systems; asthma is localized to the respiratory system, while eczema is localized to the skin.[28]

After the chemical mediators of the acute response subside, late-phase responses can often happen due to the migration of other white blood cells such as neutrophils, lymphocytes, eosinophils, and macrophages to the initial reaction sites.

This is generally seen 2–24 hours after the original reaction.[29] Cytokines from mast cells may also frolic a role in the persistence of long-term effects. Late-phase responses seen in asthma are slightly diverse from those seen in other allergic responses, although they are still caused by release of mediators from eosinophils.[30]

Six major allergenic proteins from cow’s milk own been identified: αs1-, αs2-, β-, and κ-casein from casein proteins and α-lactalbumin and β-lactoglobulin from whey proteins. There is some cross-reactivity with soy protein, particularly in non-IgE mediated allergy.

Heat can reduce allergenic potential, so dairy ingredients in baked goods may be less likely to trigger a reaction than milk or cheese. For milk allergy, non-IgE-mediated responses are more common than IgE-mediated. The previous can manifest as atopic dermatitis and gastrointestinal symptoms, especially in infants and young children.

What medicine is excellent for allergies while breastfeeding

Some will display both, so that a kid could react to an oral food challenge with respiratory symptoms and hives (skin rash), followed a day or two later with a flare up of atopic dermatitis and gastrointestinal symptoms, including chronic diarrhea, blood in the stools, gastroesophageal reflux disease (GERD), constipation, chronic vomiting and colic.[2]


Prognosis

Milk allergy typically presents in the first year of life. The majority of children outgrow milk allergy by the age of ten years.[8][13] One large clinical trial reported resolutions of 19% by age 4 years, 42% by age 8 years, 64% by age 12 years, and 79% by 16 years.[64] Children are often better capable to tolerate milk as an ingredient in baked goods relative to liquid milk.

Childhood predictors for adult-persistence are anaphylaxis, high milk-specific serum IgE, robust response to the skin prick test and absence of tolerance to milk-containing baked foods.[13] Resolution was more likely if baseline serum IgE was lower,[64] or if IgE-mediated allergy was absent so that every that was present was cell-mediated, non-IgE allergy.[8] People with confirmed cow’s milk allergy may also protest an allergic response to beef, more so to rare beef versus well-cooked beef. The offending protein appears to be bovine serum albumin.[65]

Milk allergy has consequences.

In a U.S. government diet and health surveys conducted in 2007–2010, 6,189 children ages 2–17 years were assessed. For those classified as cow’s milk allergic at the time of the survey, mean weight, height and body-mass index were significantly lower than their non-allergic peers. This was not true for children with other food allergies. Diet assessment showed a significant 23% reduction of calcium intake and near-significant trends for lower vitamin D and entire calorie intake.[66]


Treatment

The need for a dairy-free diet should be reevaluated every six months by testing milk-containing products low on the «milk ladder», such as fully cooked, i.e., baked foods, containing milk, in which the milk proteins own been denatured, and ending with unused cheese and milk.[8][48] Desensitization via oral immunotherapy is considered experimental.[49]

Treatment for accidental ingestion of milk products by allergic individuals varies depending on the sensitivity of the person.

An antihistamine, such as diphenhydramine (Benadryl), may be prescribed. Sometimes prednisone will be prescribed to prevent a possible late-phase type I hypersensitivity reaction.[50] Severe allergic reactions (anaphylaxis) may require treatment with an epinephrine pen, i.e., an injection device designed to be used by a non-healthcare professional when emergency treatment is warranted. A second dose is needed in 16–35% of episodes.[51]

Avoiding dairy

Further information: Milk allergy § Regulation of labeling

Most people discover it necessary to strictly avoid any item containing dairy ingredients.[9] The reason is that the individual threshold dose capable of provoking an allergic reaction can be fairly little, especially in infants.

An estimated 5% react to less than 30 milligrams of dairy proteins, and 1% react to less than 1 milligram.[52] A more recent review calculated that the eliciting threshold dose for an allergic reaction in 1% of people (ED01) with confirmed cow’s milk allergy is 0.1 mg of cow’s milk protein.[53]

Beyond the obvious (anything with milk, cheese, cream, curd, butter, ghee or yogurt in the name), in countries where allergen labeling is mandatory, the ingredient list is supposed to list every ingredients. Anyone with or caring for a person with a dairy protein allergy should always carefully read food package labels, as sometimes even a familiar brand undergoes an ingredient change.[54] In the U.S., for every foods except meat, poultry and egg processed products and most alcoholic beverages, if an ingredient is derived from one of the required-label allergens, then it must either own the food name in parentheses, for example «Casein (milk),» or as an alternative, there must be a statement separate but adjacent to the ingredients list: «Contains milk» (and any other of the allergens with mandatory labeling).[5][54][55][56] Dairy-sourced protein ingredients include casein, caseinates, whey and lactalbumin, among others.[54][57] The U.S.

FDA has a recall process for foods that contain undeclared allergenic ingredients.[58] The University of Wisconsin has a list of foods that may contain dairy proteins, yet are not always obvious from the name or type of food.[57] This list contains the following examples:

There is a distinction between “Contains ___” and “May contain ___.” The first is a deliberate addition to the ingredients of a food, and is required. The second addresses unintentional possible inclusion of ingredients, in this instance dairy-sourced, during transportation, storage or at the manufacturing site, and is voluntary, and is referred to as precautionary allergen labeling (PAL).[5][54][11]

Milk from other mammalian species (goat, sheep, etc.) should not be used as a substitute for cow’s milk, as milk proteins from other mammals are often cross-reactive.[59] Nevertheless, some people with cow’s milk allergy can tolerate goat’s or sheep’s milk, and vice versa.

Milk from camels, pigs, reindeer, horses, and donkeys may also be tolerated in some cases.[47]Probiotic products own been tested, and some found to contain milk proteins which were not always indicated on the labels.[60][61]

Cross-reactivity with soy

Infants – either still 100% breastfeeding or on baby formula – and also young children may be prone to a combined cow’s milk and soy protein allergy, referred to as «milk soy protein intolerance» (MSPI).

A U.S. state government website presents the concept, including a recommendation that nursing mothers discontinue eating any foods that contain dairy or soy ingredients.[62] In opposition to this recommendation, a published scientific review stated that there was not yet sufficient evidence in the human trial literature to conclude that maternal dietary food avoidance during lactation would prevent or treat allergic symptoms in breastfed infants.[41]

A review presented information on milk allergy, soy allergy and cross-reactivity between the two. Milk allergy was described as occurring in 2.2% to 2.8% of infants and declining with age.

Soy allergy was described as occurring in zero to 0.7% of young children. According to several studies cited in the review, between 10% and 14% of infants and young children with confirmed cow’s milk allergy were sure to also be sensitized to soy and in some instances own a clinical reaction after consuming a soy-containing food. The research did not address whether the cause was two separate allergies or a cross-reaction due to a similarity in protein structure, as which occurs for cow’s milk and goat’s milk.[47] Recommendations are that infants diagnosed as allergic to cow’s milk baby formula be switched to an extensively hydrolyzed protein formula rather than a soy whole protein formula.[47][63]


Prevention

Research on prevention addresses the question of whether it is possible to reduce the risk of developing an allergy in the first put.

Reviews concluded that there is no strong evidence to recommend changes to the diets of pregnant or nursing women as a means of preventing the development of food allergy in their infants.[40][41][42] For mothers of infants considered at high risk of developing cow’s milk allergy because of a family history, there is some evidence that the nursing mom avoiding allergens may reduce risk of the kid developing eczema, but a Cochrane review concluded that more research is needed.[41]

Guidelines from various government and international organizations recommend that for the lowest allergy risk, infants be exclusively breastfed for 4–6 months.

There does not appear to be any benefit to extending that period beyond six months.[42][43] If a nursing mom decides to start feeding with an baby formula prior to four months the recommendation is to use a formula containing cow’s milk proteins.[44]

A diverse consideration occurs when there is a family history – either parents or older siblings – of milk allergy. The three options to avoiding formula with intact cow’s milk proteins are substituting a product containing either extensively hydrolyzed milk proteins, or a non-dairy formula, or one utilizing free amino acids.

The hydrolyzation process breaks intact proteins into fragments, in theory reducing allergenic potential. In 2016, the U.S. Food and Drug istration (FDA) approved a label claim for hydrolyzed whey protein being hypoallergenic.[45] However, a meta-analysis published the same year disputed this claim, concluding that, based on dozens of clinical trials, there was insufficient evidence to support a claim that a partially hydrolyzed formula could reduce the risk of eczema.[46] Soy formula is a common substitution, but infants with milk allergy may also own an allergic response to soy formula.[47] Hydrolyzed rice formula is an option, as are the more expensive amino acid-based formulas.[44]


Diagnosis

Further information: Food allergy

Diagnosis of milk allergy is based on the person’s history of allergic reactions, skin prick test (SPT), patch test, and measurement of milk protein specific serum IgE.

A negative IgE test does not law out non-IgE-mediated allergy, also described as cell-mediated allergy. Confirmation is by double-blind, placebo-controlled food challenges, conducted by an allergy specialist. SPT and IgE own a sensitivity of around 88% but specificity of 68% and 48%, respectively, meaning these tests will probably detect a milk sensitivity but may also be false-positive for other allergens.[31]

Attempts own been made to identify SPT and IgE responses precise enough to avoid the need for confirmation with an oral food challenge.

A systematic review stated that in children younger than two years, cut-offs for specific IgE or SPT seem to be more homogeneous and may be proposed. For older children, the tests were less consistent. It concluded «None of the cut-offs proposed in the literature can be used to definitely confirm cow’s milk allergy diagnosis, either to unused pasteurized or to baked milk.»[32]

Differential diagnosis

The symptoms of milk allergy can be confused with other disorders that present similar clinical features, such as lactose intolerance, infectious gastroenteritis, celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease, eosinophilic gastroenteritis, and pancreatic insufficiency, among others.[33][34][35]

Lactose intolerance

Main article: Lactose intolerance

Milk allergy is distinct from lactose intolerance, which is a nonallergic food sensitivity, due to the lack of the enzymelactase in the little intestines to break lactose below into glucose and galactose.

The unabsorbed lactose reaches the large intestine, where resident bacteria use it for fuel, releasing hydrogen, carbon dioxide and methane gases. These gases are the cause of abdominal pain and other symptoms.[33][36] Lactose intolerance does not cause damage to the gastrointestinal tract.[37] There are four types: primary, secondary, developmental, and congenital.[38] Primary lactose intolerance is when the quantity of lactase declines as people age.[38] Secondary lactose intolerance is due to injury to the little intestine, such as from infection, celiac disease, inflammatory bowel disease, or other diseases.[38][39] Developmental lactose intolerance may happen in premature babies and generally improves over a short period of time.[38] Congenital lactose intolerance is an extremely rare genetic disorder in which little or no lactase is made from birth.[38]


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