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评论:牛奶牛奶暴露在婴儿期和经常性喘息

评论
12/14/2020 James Jeffrey Malatack,MD,托马斯杰斐逊大学的Sidney Kimmel医学院儿科教授

牛奶的人体过敏是医疗专业人士的兴趣多十年。牛奶主要被婴儿和儿童消费,牛的牛奶致敏可能发生在婴儿期,因此,儿科特殊地侧重于理解牛奶蛋白作为人类过敏性疾病原因的机制和影响。

Hiroshi Tachimoto和同事在最近的出版物(1)中权衡了这次讨论。这是一种可爱的努力,因为事先研究既有牵引和牛奶作为人类过敏性疾病和喘息的因果。该研究在单个东京医院进行,作为随机但未粘连的(研究参与者是婴儿,但父母被揭穿)研究。T.he newborns studied were selected from families in which the risk of allergy was above the mean and then randomized into two equal groups to receive either breast feeding with or without supplemental elemental formula or breast feeding with cow’s milk supplemental feeding during the first 3 days of life. The participants were then assessed at five months and at two years of life by physicians blinded to the study design for the presence allergic disease including wheezing. Those patients who had clinical or laboratory evidence of allergic disease at two years were followed until age six. About half the patients met the criteria for the longer follow up.

该研究最终在两项研究肢体中的每一个最终由151名新生儿组成,发现两组之间的结果差异显着差异。T.he infants who received breast feeding supplemented with cow’s milk in the first three days of life had a recurrent wheezing/asthma rate of 17.9% (27 newborns) in follow-up while those who avoided cow’s milk in those first three days of life (breast feeding with or without elemental formula supplementation) had a follow-up recurrent wheezing/asthma rate of 9.9% (15 newborns). The newborns who received supplemental cow’s milk were to continue this feeding regimen until 5 months while the group receiving breast feeding with or without elemental formula supplementation change diet. This latter group appears to have self-randomized to either quickly add cow’s milk supplementation to their diet before 14 days, to add cow’s milk to the diet after 14 days, or to maintain breast feeding with or without supplemental elemental formula and no cow’s milk for 5 months.

作者认为,他们控制了可能影响研究结果的所有变量,留下牛奶作为生命的第一天发生的唯一随机化。这是对可变控制的推定,保证更仔细的外观。可变控制以及许多潜在的混乱可能会影响研究或其解​​释:

1.盲目盲目的失败(实际上,参与者的父母)可能在随机化中添加了错误。应该指出的是,随着研究的构思,父母是不可能的。E.lemental formula is readily recognized by differing appearance and odor in comparison to cow’s milk such that the parents, even if initially blinded, would rapidly appreciate what limb of the study their child was in. One needs to wonder whether in these families with known allergy, would parents, aware that their child did not get cow’s milk, be more likely to avoid cow’s milk in the future. When parents in the first five months of life either added cow’s milk before 14 days or after 14 days or maintained the cow’s milk-free regimen until 5 months, how would this knowledge have influenced the parents’ behavior after 5 months? How would this information impact the mothers’ own diet? Conversely, parents in the group continuing cow’s milk supplementation for five months who realized that their infants were already sensitized to cow’s milk, would mothers be more likely to continue cow’s milk after that and how would it impact on their own diet? How likely would they be to accept other potential food allergens as infant feedings?

2.没有讨论牛奶数量,数量可能很重要。如果在14天,父母决定停止使用元素配方补充,以支持牛奶补充剂,但母乳体积使得不需要补充剂,将提供任何补充剂吗?如果是这样,将提供多少钱?如果提供给一个婴儿,将消费多少钱?这种定量信息可能是至关重要的。

3.患者群体来自有背景信息的患者提出,表明Atact的风险。作者解释说,他们来自东京的富裕地区,具有非常均匀的种族,通过清洁假设可能更有可能被过敏原敏感。本研究可能根本不适用于一般人群。

4.作者只遵循患者在2年内达到特性的研究标准,直到六岁。由于没有研究过2年的特性标准的患者,一个人奇观可能在未捕获的群体中有多少“晚喘息率”,这可能会否定研究的结论。这是一个非常重要的考虑因素,因为平均喘息时间超过2年。

5.失败是否会影响父母改变他们对其他潜在敏感剂的行为?

该研究还评估了牛奶的前三天干预的有效性,或者没有牛奶补充的乳牛乳补充,由25(OH)D水平影响。在5个月和2年内评估25(OH)D的水平。一世nfants with a higher vitamin D level (> 29 ng/mL) at 5 months had a more dramatic reduction in the risk of recurrent wheezing/asthma in the no cow’s milk group than those infants who had a lower level for 25(OH)D (< 29 ng/mL) in which no beneficial effect of the absence of cow’s milk exposure was seen. No vitamin D effect was seen at two years.

一世gE was assessed at 5 months and at 2 years as well and, while no effect of the IgE level was observed at 5 months, at two years those infants with the highest IgE levels had less wheezing if they had not received cow’s milk supplements in the first three days of life. Because of the concerns raised above, the impact of either Vitamin D or IgE level as related to the first three days of life randomization is unclear.

这项研究很复杂,文章是用内部矛盾写的,这增加了阅读和理解它的难度。作为一个例子,试验设计部分的第二句指出,两项研究肢体粘附在饲养设计中,直到5个月的年龄。后来,在结果部分中,读者被告知,在生命的前五个月内进一步分为三组,其中两个婴儿进一步喂养乳房喂养中的婴儿,其中两组尚未“粘附在饲养设计中。直到5个月。“

如果复苏工作,人们会产生什么感兴趣的?如果数据持有并克服上面提出的担忧,问题是为什么生命的前三天这么重要?也许新生儿的频繁但正常的胃肠道反流可能与肺部的微自痉挛和直接敏化与过敏原相关联,该过敏原形成复发喘息的过程。我相信,最终有太多的担忧,允许它允许它影响现有的做法,但Tachimoto和同事提出的问题关于是否存在关于生命前三天非常特别的东西和对牛奶的敏感性或者对于其他食物过敏原的物质是有趣的并且应该得到更多的研究。

参考

Tachimoto H,Imanari E,Mezawa M,等:避免牛奶配方在出生时避免患有哮喘或幼儿的经常性喘息的疗效:ABC随机临床试验的延长后期。Jama Netw开放10月1日;3(10):E2018534,2020。DOI:10.1001 / JamanetWorkopen.202010.18534