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© Kaliuzhka E. A.
UDC 613.953.11:616-056.3-084 Kaliuzhka E. A.
BREASTFEEDING AS PREVENTION OF CHILDREN'S ATOPY (LITERATURE REVIEW)
Ukrainian Medical Stomatological Academy (Poltava)
This work is a fragment of scientific research «Development of methods for the selection of contingent for work connected with biological safety motivated by identify individual characteristics of genotype», № state registration 0114U00785, № state registration 0114U003088.
Atopic dermatitis is now considered as a systemic disease because the pathological process involved not only the skin but other organs and systems of man [1,2,3]. Atopic dermatitis (AD) is a chronic allergic disease developing in individuals with a genetic predisposition to atopy and characterized by rash, recurrent course, hypersensitivity to specific (allergens) and nonspecific stimuli and rising level of IgE.
Despite the large number of preventive means, recent years we have seen a significant increase of allergic diseases that becomes a global problem that reaches such scopes that some scientists call it an epidemic of the XXI century. So, for the last 40 years the frequency of asthma, food allergies and atopic dermatitis has increased twice. According to the WHO, one in five people on the planet suffer from allergic reactions or pseudo-allergic reactions. From 30 to 90% of the population does not endure one or more foodstuff, but true food allergy develops in only 5-6% of children and 3-4% of adults. In all other cases food intolerance is marked, which is not linked to immune reactions to food [5,8,13,19].
Much attention has attracted the problem of nutrition of children, especially infants and young children. The reason for this - irrational feeding of children under this scenario, which further leads to growth disorders, intellectual development, and certain diseases in adolescence [12,14,15].
Most allergic reactions occur in children during the first three years of life due to food allergies. The term «food allergy» should be used only when proven immu-nologically mediated hypersensitivity reaction to any component of food, including IgE-positive and/or IgE-negative allergic reactions [9]. Food allergies can cause development of not only atopic dermatitis, but allergic rhinitis, asthma, and others. This transition of one allergic state to another is called allergic march [8,10,13].
Increase of the frequency of allergic diseases that reduce quality of children life and can lead to chronic diseases and early disability, as well as prevention of food allergy is very important and relevant at the present [5,19,25].
Unfortunately, children's eczema is not fully studied problem. The disease is closely linked with the problems of ecology, psycho-load, low-quality food. Other factors that may lead to the development of this disease
include: reduction of terms of breastfeeding, artificial feeding, early introduction of complementary foods. It can provoke an aggravation such adverse factors as infectious, bacterial, viral or fungal disease [2,4,8].
The basis of this disease in children in the vast majority are Ig E-mediated immunopathological reactions, but more than 30% of patients with this pathology does not register elevated levels of IgE. So, this children group as basis atopic dermatitis has other immune and non-immune mechanisms of inflammation.
In recent years greatly expanded representation on the role in the formation of skin immune response to an allergen. Today it is proved that skin is just the body that directly participates actively in the development of atopic reactions. Getting immune response occurs in an associated skin lymphoid tissue (SALT - skin associated lymphoid tissue). Dendritic cells of skin first recognize and capture the antigen and migrating to the regional lymph nodes, present it to T-cells. Just a cascade of immune reactions occurs in the lymph nodes of regional, which in turn lead to the transformation of B-cells into plasma cells, which are synthesized antibodies. Further antibodies and sensitized lymphocytes are returned to the skin and lead to implementation of immune inflammatory response, which clinically manifested symptoms of atopic dermatitis [5,8,9].
In the classification of atopic dermatitis the following periods distinguish.
1. Period of the baby is from birth to 2 years old child. Factors that cause the appearance of dermatitis in infants is unbalanced diet during pregnancy and lactation, taking certain drugs, and the presence of her infection. The most common manifestations of dermatitis in these children are extensor surface of the extremities, face, and torso. There is redness of the cheeks and buttocks with further formation of crusts in these areas. Remember that one of the periods of exacerbation is defined teething and introduction of complementary foods.
2. Kids period, which lasts from 2 to 12 years. The rash can often occur on flexor surfaces of the extremities, the elbow and popliteal pits, and neck. The clinical picture is characterized by swelling of the skin, there is a crack, crust, and erosion.
3. Adolescence is 12 to 18 years. In this age (especially in boys) there are two variants of the disease. Firstly - there is a high probability of disappearance of lesions, and secondly - a sharp aggravation of dermatitis, accompanied by increasing amounts of damage (neck and neck area, face, wrist and elbow pits, and the skin of the hands).
4. Adulthood. In this period, the most vulnerable are places such as: neck and face, fingers, dorsum of the hand and foot with characteristic dryness and itching of the skin, peeling, rash, and thickening of the skin with increased skin picture. Formed a vicious circle: the itch - scratch - rash - itchy. To establish a final diagnosis of atopic dermatitis we must first rule out other options of diseases such as: allergic contact dermatitis, scabies, seborrheic dermatitis, psoriasis, and others.
The main prognostic risk factors for food allergy include: genetic predisposition, early artificial feeding, early unwarranted introduction of products with high allergenicity, the effect of allergens (food fibers, dust, animals, mites, etc.), and other factors (passive smoking, seasonal vegetable allergens, industrial pollution of the environment, etc.).
In the first year of life of children who live in the European region on first place among food there are such allergens: cow's milk proteins (b-lactoglobulin, a-lactoglobulin, casein), eggs (ovalbumin, ovomukoid), fish (M-paralbumin), and the second - cereal proteins (gluten, gliadin), wheat, corn, rice, and buckwheat less [1,2,4].
Recommendations for prevention of food allergy were developed by ESPACI, ESPGHAN, and the American Academy of Pediatrics in 1999 believed that the main task of population of children with atopy is a risk of promotion and sale of breastfeeding. In international and national guidelines stress the necessity of breast feeding children during the first 4-6 months of life [24].
Currently, there is no doubt that breast milk of a healthy mother is the ideal food for infants and is the main preventive measure for the development of food allergy in children of this age group [10,11,27].
Recently, many countries developed adverse situation associated with early abandonment of breastfeeding [10,11]. Ministry of Health of Ukraine developed and approved a program of support for breastfeeding children in Ukraine. For this purpose, the principals support lactation and breastfeeding infants based on the policy recommendations of the WHO/UNICEF, based on the performance of ten principles of successful breastfeeding, some changes of the timing of administration corrective supplements and foods for children who are breastfed [8,9,11]. Breast milk prevents colonization of intestine of newborn child by pathogenic microorganisms and prevents intestinal dysbiosis, food allergies, and other digestive diseases [8,10].
Breastfeeding is unique in nature because only breast milk can provide baby the necessary number of proteins, fats, carbohydrates, vitamins, and biologically active substances, enzymes, hormones, immunoglobu-lins. These components are virtually impossible to enter into the artificial breast milk substitutes. A child that in the first year of life was breastfed, in the future he will be less vulnerable to allergies. So, it worth fighting for breastfeeding. And one of the main help in the proper nutrition of nursing mothers. A woman should strictly adhere to the basics of nutrition, i.e. feed as well as fed before and during pregnancy, but some increase protein in the diet, because it loses protein from human milk [9,10].
There are also other types of feeding infants, namely artificial and mixed feeding. A child with such feeding may not receive breast milk or its number is less than 1/5 of the volume of food and staple food is artificial mixture [8,9,11].
Today we understand that feeding infants by unmodified cow's milk can lead to various disorders in child development, the emergence of pathological reactions of food hypersensitivity, allergic and autoimmune diseases, disorders of the immune system, increasing the risk of infectious diseases. It is known that about 13% of children in the first year of life get cow's milk, and 4% of infants are fed by only cow's milk, 18% - formula and cow's milk. In the second year of life and in the future for the majority of children nutrition is a typical use of unmodified cow's milk.
Today it is proved that early consumption of cow's milk has several pathological mechanisms that act simultaneously, which leads to increased adverse effects. Lack of oligosaccharides and other necessary biologically active substances in cow's milk leads to disturbances in the formation of intestinal microflora of child, adequate mechanisms of immune protection, food tolerance. A small amount of iron in cow's milk causes the development of chronic iron deficiency, which leads to disruption of normal metabolism of a child, increases the risk of iron deficiency anemia, and other deficiency states. The abundance of calcium and casein in milk leads to further malabsorption of iron in intestine of child. Infants who consume cow's milk, get more protein and minerals compared with children who are on breastfeeding, leading to overload the kidneys, causing them to work hard and devote more liquid. In cow's milk protein contains a number of allergens that can trigger varied allergic reactions. Later discrepancy of cow's milk physiological needs of the child can provoke development of various diseases such as obesity, diabetes, hypertension, Crohn's disease, enteropathy, atopic dermatitis, asthma, headaches, attention deficit hyperactivity disorder, rheumatoid arthritis, osteoporosis, and others. In modern literature there is more information about the close correlation between diseases that occur in adulthood and the nature of power in the first year of life.
Despite the clear advantages of breastfeeding, the reality now is that the proportion of children who are bottle-fed are still very high. In this connection it is necessary to develop high quality products for artificial feeding, the composition of which must be as much as possible close to the composition of human milk. It is clear that many of the effects of breastfeeding can not be simulated. These include first and foremost a very important and powerful factor in psychological contact of mother and child during feeding. It is difficult and perhaps impossible to fully reproduce strictly individual and complex adaptive immune factors that make human milk provides immune defense and the formation of the immune system of the baby, as well as establishment of normal microflora of intestine of child. Yet the development of mixtures for artificial feeding for more than sesquicentennial history of development has made considerable progress, which now allows to provide the body of a small child by necessary nutrients and remove
most of the adverse effects associated with the inability of breastfeeding. This is a high-quality tailored mix, the choice is now large enough [8,10,13,16].
In most cases, the basis of modern artificial feeding formula is cow's milk. At the same time, cow's milk compared to women, contains higher protein and lower fat and carbohydrates. Furthermore, proteins and fats differ in their properties and chemical composition. Cow's milk contains more potassium, sodium, and some other minerals and less - vitamins. In this connection it is necessary to adapt cow's milk for children complete food that has no side effects. The introduction of the mixture of whey protein can increase the proportion of easily digestible protein, similar in amino acid composition to human milk proteins, reducing the proportion of casein, which prevails in the composition of cow's milk. In some cases it is demineralized whey of cow's milk is used as a mixture. Fat cow's milk partially or fully replaced by vegetable fats (usually from sunflower, corn, soybean, coconut or palm oil). In modern mixtures for artificial feeding is usually increased proportion of easily digestible medium chain acids (commonly achieved by introducing coconut oil) and essential for normal growth of lipids containing linoleic and linolenic fatty acids (the first part of the sunflower and corn oil, second - coconut and some others). Often mixtures are introduced into the emulsifier (often - lecithin) and modulators of lipid metabolism (carnitine). Correction of carbohydrate is provided by increasing the concentration of lactose in milk or entering dextrinmaltoza in it or containing its natural products (malt extract, corn syrup, etc.). So, «basic» preparation of cow's milk is carried, most approaching it for the major components of the human milk.
Today, in addition to mixtures based on cow's milk, there are foods for infants produced from goat's milk. Goat milk also requires adaptation, because it contains high amounts of protein, salt, and too little carbohydrates. Goat milk (milk formulas as a basis) is favorably different from cow by the number of properties. In goat milk fat globules are much smaller in size and have a second fatty acid composition, which greatly facilitates the assimilation of milk fat. Iron of goat's milk is absorbed by children of first year of life more fully than iron contained in the composition of cow's milk.
In addition, special therapeutic mixture is carried out based on soy proteins and protein hydrolysates.
For normal growth and development of children it is also required balanced composition of macro- and micronutrients, vitamins, and some other biologically active components found in human milk. Trace element composition including through the introduction of iodine and selenium (the name of mix often does not change) significantly improved in modern mixtures. Must provided the best content and ratio of calcium and phosphorus, and the availability of preventive doses of vitamin D. Also iron is introduced in the mix - given the possible development of its deficit. In most compounds they administered taurine, an amino acid which is important serincontaining with content in cow's milk (unlike the female) is very low. N Taurine is required for normal development of the nervous system and lipid metabolism.
Currently in our country and abroad it produced a wide range of breast milk substitutes, among which
there are dry, liquid, and fresh milk. But much more important is human milk substitutes division according to their approach to the composition of human milk into two groups: highly adapted, less adapted and partially adapted [12,19].
Adapted substitutes most close to human milk in all respects, and especially for protein, they are reduced in comparison with cow's milk, the total protein content (to 1,4-1,6 g/100 ml) which eliminates the adverse impact that excess protein has on nitrogen and mineral metabolism of baby, its digestive function and immature kidneys. This protein component is represented by a mixture of casein (the main protein of cow's milk) and whey proteins, dominant in human milk, in a ratio of 40:60 or 50:50. It's close to their ratio in mature human milk (45:55). N whey proteins form in the stomach hydrochloric acid under the influence much more gentle and finely dispersed clot than casein, which provides them the best attacked by digestive enzymes and therefore a higher degree of digestion and assimilation. In addition, the introduction of substitutes for human milk by whey protein allows some degree approximate amino acid composition of the mixture to the amino acid composition of human milk [11,12,15,19].
In substitutes of this class optimize the composition of fatty component - the milk fat is fully or partially replaced by a mixture of vegetable oils (sunflower, corn, soybean, rapeseed, coconut, palm, etc.), which are selected in such proportions as to ensure maximum approximation of the fatty acid composition of milk formulas for fatty acid composition of human milk. This change is necessary because the fat cow's milk contains a different combination of fatty acids than human milk fat: it has a higher content of saturated fatty acids but lower level of w-6 families polyunsaturated fatty acids (linoleic) and w-3 families (linolenic, dokozoheksaenic, and eikozopentaenic acid). N on this basis adapted to human milk substitutes milk fat partially or completely replaced by a mixture of natural vegetable oils - sunflower, corn, soybean, coconut, palm, etc. However, the contrary is the problem of maintaining a part of human milk substitutes for butterfat. This approach is perhaps more rational, because keeping adapted cow milk fat in milk mixture (up to 25% of the total fat content in the product), we improve the organoleptic properties of the product and ensure the presence in its composition of small amounts of cholesterol, which hinders the flow (the mechanism of «feedback») endogenous synthesis of steroids, though it leads to increased levels in the blood.
The main carbohydrate in majority of human milk substitutes is lactose, which has several properties that have important physiological significance for babies. It promotes the absorption of calcium, has bifidogenic effect (i. e. the ability to support the growth of bifido-bacteria), lowers the pH in the colon. The last two of its properties due to the fact that part of the lactose is not absorbed in the small intestine and enters the colon, which serves as a substrate for B. bifidus, under the influence of which it undergoes fermentation to form lactic acid [8,9,19,20]. These blends recommend children under the age of 4-5 months, and in some cases they can be used up to a year. In addition, there are dried milk
formula, the title of which has prefix «pre» or number «0», these products are administered to newborns and premature babies [17,19,20].
Less adapted milk formula include casein formula. Their name is due to the fact that they are prepared based on conventional cow's milk, which main protein is casein. The basic structure of casein formula is Polyunsaturated fatty acids (PUFA) content, vitamins, and minerals balanced in accordance with the requirements of the second half of life, so they should be advised to children from 5-6 months of age.
Partially adapted milk formula for the hygienic indices belong to high quality and can be used in baby food in accordance with established guidelines. On the basis of dairy products can be prepared for the third feeding [19].
Thus, atopic dermatitis is a chronic disease whose symptoms are often observed throughout life and provoked by multiple different factors. Therefore, children with high risk of allergy should be 6 months fed by only breast milk. If the natural feeding is impossible, to prevent early sensitization should not be willing to give milk formula containing cow's milk, and use hypoallergenic blend.
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УДК 613.953.11:616-056.3-084
ПРИРОДНЕ ВИГОДОВУВАННЯ ЯК ПРОФ1ЛАКТИКА РОЗВИТКУ АТОПП У Д1ТЕЙ (Л1ТЕРАТУРНИЙ ОГЛЯД)
Калюжка О. О.
Резюме. Атотчний дерматит — хроычне алерпчне захворювання, що розвиваеться у oci6 схильних до атопп, та характеризуемся рецидивами, типовими висипаннями, пщвищенням чутливост до специфiчних i неспецифiчних подразниюв. В останнi роки збiльшилася частота захворюваност на атопiчний дерматит серед дитячого населення. Одыею з причин цього захворювання е нерацюнальне харчування дтей першого року життя. Ранне вщлучення вiд грудей, штучне вигодовування, нерацюнальне та ранне введення прикорму — вс ц фактори е провокуючими факторами розвитку атопiчного дерматиту. У наш час е широкий спектр замЫниюв грудного молока (молочн сумш^. У бiльшостi випадкiв сучасн сумiшi виробляють з коров'ячого молока. Лкувальы сумiшi готують на основi соевих бiлкiв i бiлкових гiдролiзатiв. 1стотним е подiл замiнникiв грудного молока на двi великi групи: високо адаптоваы, мало адаптованi i частково адаптованi. Однак, не-зважаючи на це, ризик розвитку атотчного дерматиту у дiтей, якi перебувають на штучному вигодовуваннi, набагато вище, нiж у дiтей на природному вигодовуваннг Тому в рекомендацiях щодо профiлактики розвитку даного захворювання основна роль выводиться грудному вигодовуванню дггей першого року життя.
Ключовi слова: атотчний дерматит, харчова алергiя, дитяча екзема, штучне вигодовування, молочн сумшг
УДК 613.953.11:616-056.3-084
ЕСТЕСТВЕННОЕ ВСКАРМЛИВАНИЕ КАК ПРОФИЛАКТИКА РАЗВИТИЯ АТОПИИ У ДЕТЕЙ (ОБЗОР ЛИТЕРАТУРЫ)
Калюжка Е. А.
Резюме. Атопический дерматит - хроническое аллергическое заболевание, развивающееся у лиц склонных к атопии, характеризующееся рецидивами, типичными высыпаниями, гиперчувствительностью к специфическим и неспецифическим раздражителям. В последние годы увеличилась частота заболеваемости атопическим дерматитом среди детского населения. Одной из причин данного заболевания является нерациональное питание детей, особенно грудного возраста. Раннее отлучение от груди, искусственное вскармливание, раннее введение прикорма - все эти факторы являются провокаторами развития атопи-ческого дерматита. В наше время выпускается широкий спектр заменителей грудного молока (молочные смеси). В большинстве случаев современные смеси производят из коровьего молока. Лечебные смеси готовят на основе соевых белков и белковых гидролизатов. Существенным является разделение заменителей грудного молока на две большие группы: высоко адаптированные, мало адаптированные и частично адаптированные. Однако, несмотря на это, риск развития атопического дерматита у детей находящихся на искусственном вскармливании гораздо выше, чем у детей на естественном вскармливании. Поэтому, в рекомендациях по профилактике развития данного заболевания основная роль отводится грудному вскармливанию детей первого года жизни.
Ключевые слова: атопический дерматит, пищевая аллергия, детская экзема, искусственное вскармливание, молочные смеси.
UDC 613.953.11:616-056.3-084
BREASTFEEDING AS PREVENTION OF CHILDREN'S ATOPY (LITERATURE REVIEW)
Kaliuzhka E. A.
Abstract. Atopic dermatitis is a chronic allergic disease. It develops in individuals prone to atopy and is characterized by relapses, a typical rash, and sensitivity to specific and nonspecific stimuli. Last years grew incidence of atopic dermatitis among children.
Most allergic reactions occur in children during the first three years of life as a result of food allergies, which can cause not only development not only atopic dermatitis, and allergic rhinitis, asthma and more.
The main prognostic risk factors for the development of food allergy include: genetic predisposition, early artificial feeding, early introduction of products unreasonable high allergens, the effect of allergens (food proteins, dust, animals, ticks) and additional factors (passive smoking, seasonal vegetable allergens, industrial pollution of the external environment).
One of the reasons this disease is improper feeding of children first year of life. Early weaning, artificial feeding, irrational, and early introduction of complementary foods — all of these factors are precipitating factors in the development of atopic dermatitis.
Recommended preventive measures for food allergies developed ESPACI, ESPGHAN and the American Academy of Pediatrics. The main objective of these guidelines is the promotion and implementation of breastfeeding. In international and national guidelines stress the necessity of breast feeding children during the first 4-6 months of life.
Breastfeeding is unique in its nature, so that only breast milk can provide baby the necessary number of proteins, fats, carbohydrates, vitamins and biologically active substances, enzymes, hormones, immunoglobulins. It prevents colonization of the intestine of the newborn from pathogenic microorganisms and prevents the development of intestinal disbiosis, food allergies and other diseases of the digestive system. Breast milk of healthy mother is the ideal food for infants in the first year of life and the main preventive measure against development of food allergies among children in this age group.
There are also other types of feeding children the first year of life, for example, artificial and mixed feeding. Use in the first year of life an unmodified cow's milk may cause various disorders in the development of the child, the appearance of pathological reactions of food hypersensitivity, allergic and autoimmune diseases, and disorders of the immune system, greater risk of infectious diseases. Early introduction of cow's milk diet a child leads to the launch of pathological mechanisms that act simultaneously, which leads to increased adverse effects.
Nowadays there are a wide range of breast milk substitutes (infant formula). Most of the modern mix made from cow's milk. Treating mixture prepared from soy protein and protein hydrolysates. It is essential division of Breastmilk Substitutes into two groups: highly adaptable, had adapted and partially adapted. However, despite this, the risks of atopic dermatitis among children who are bottle-fed are much higher than in children breastfed. Therefore, recommendations for the prevention of the development of the disease the main role has given to breastfeeding infants in the first year of life.
Keywords: atopic dermatitis, food allergy, children eczema, artificial feeding, milk formula.
Рецензент — проф. Похилько В. I.
Стаття надшшла 03.10.2016 року
