Abstract

Background: The persistently high prevalence of allergic diseases in Western industrial nations and the limited possibilities of causal therapy make evidence-based recommendations for primary prevention necessary. Methods: The recommendations of the S3 Guideline Allergy Prevention, published in its last version in 2014, were revised and consented on the basis of a current systematic literature search. The evidence search was conducted for the period 06/2013 – 11/2020 in the electronic databases Cochrane and MEDLINE, as well as in the reference lists of current reviews and through references from experts. The literature found was screened in two filtering processes, first by title and abstract, and the remaining papers were screened in the full text for relevance. The studies included were sorted by level of evidence, and the study quality was indicated in terms of potential bias (low/high). The revised recommendations were formally agreed and consented upon with the participation of representatives of the relevant professional societies and (self-help) organizations (nominal group process). Of 5,681 hits, 286 studies were included and assessed. Results: Recommendations on maternal nutrition during pregnancy and breastfeeding as well as on infant nutrition in the first months of life again play an important role in the updated guideline: Many of the previous recommendations were confirmed by the current data. It was specified that breastfeeding should be exclusive for the first 4 – 6 months after birth, if possible, and that breastfeeding should continue with the introduction of complementary foods. A new recommendation is that supplementary feeding of cow’s milk-based infant formula should be avoided in the first days of life if the mother wishes to breastfeed. Furthermore, it was found that the evidence for a clear recommendation for hydrolyzed infant formula in nonbreastfed infants at risk of atopic diseases is currently insufficient. It is therefore recommended to check whether an infant formula with proven efficacy, demonstrated in allergy prevention studies, is available until the introduction of complementary feeding. Finally, based on the EAACI guideline, recommendations were made for the prevention of hen’s egg allergy by introducing and regularly giving thoroughly heated (e.g., baked or hard-boiled) but not “raw” hen’s egg (also no scrambled egg) with the complementary food. The recommendation to introduce peanut in complementary feeding was formulated cautiously for the German-speaking countries: In families with regular peanut consumption, the regular administration of peanut-containing foods in ageappropriate form (e.g., peanut butter) with the complementary diet can be considered for the primary prevention of peanut allergy in infants with atopic dermatitis (AD). Before introduction, a clinically relevant peanut allergy must be ruled out, especially in infants with moderate to severe AD. There is still insufficient evidence for an allergy-preventive efficacy of prebiotics or probiotics, vitamin D, or other vitamins in the form of supplements so that recommendations against their supplementation were adopted for the first time in the current guideline. Biodiversity plays an important role in the development of immunological tolerance to environmental and food allergens: there is clear evidence that growing up on a farm is associated with a lower risk of developing asthma and allergic diseases. This is associated with early non-specific immune stimulation due to, among other things, the greater microbial biodiversity of house dust in this habitat. This aspect is also reflected in the recommendations on animal husbandry, on which a differentiated statement was made: In families without a recognizable increased allergy risk, pet keeping with cats or dogs should not generally be restricted. Families with an increased allergy risk or with children with already existing AD should not acquire a new cat – in contrast, however, dog ownership should not be discouraged. Interventions to reduce exposure to dust mite allergens in the home, such as the use of mite allergen-proof mattress covers (“encasings”), should be restricted to patients with already proven specific sensitization against house dust mite allergen. Children born by caesarean section have a slightly increased risk of asthma – this should be taken into account when advising on mode of delivery outside of emergency situations. Recent work also supports the recommendations on air pollutants: Active and passive exposure to tobacco smoke increase the risk of allergies, especially asthma, and should therefore be avoided. Exposure to nitrogen oxides, ozone, and small particles (PM 2.5) is associated with an increased risk, especially for asthma. Therefore, exposure to emissions of nitrogen oxides, ozone, and small particles (PM 2.5) should be kept low. The authors of this guideline are unanimously in favor of enacting appropriate regulations to minimize these air pollutants. There is no evidence that vaccinations increase the risk of allergies, but conversely there is evidence that vaccinations can reduce the risk of allergies. All children, including children at risk, should be vaccinated according to the current recommendations of the national public health institutes, also for allergy prevention. Conclusion: The consensus of recommendations in this guideline is based on an extensive evidence base. The update of the guideline enables evidence-based and up-to-date recommendations for the prevention of allergic diseases including asthma and atopic dermatitis.

Author Details

Authors

• Matthias V. Kopp¹
• Cathleen Muche-Borowski²
• Michael Abou-Dakn³
• Birgit Ahrens⁴
• Kirsten Beyer⁵
• Katharina Blümchen⁴
• Petra Bubel⁶
• Adam Chaker⁷
• Monika Cremer⁸
• Regina Ensenauer⁹
• Michael Gerstlauer¹⁰
• Uwe Gieler¹¹
• Inga-Marie Hübner¹²
• Fritz Horak¹³
• Ludger Klimek¹⁴
• Berthold V. Koletzko¹⁵
• Sybille Koletzko¹⁶
• Susanne Lau⁵
• Thomas Lob-Corzilius¹⁷
• Katja Nemat¹⁸
• Eva M.J. Peters¹¹
• Antonio Pizzulli†¹⁹
• Imke Reese²⁰
• Claudia Rolinck-Werninghaus²¹
• Elien Rouw²²
• Bianca Schaub²³
• Sebastian Schmidt²⁴
• Jens-Oliver Steiß²⁵
• Anne Kathrin Striegel²⁶
• Zsolt Szépfalusi²⁷
• Dietmar Schlembach²⁸
• Thomas Spindler²⁹
• Christian Taube³⁰
• Valérie Trendelenburg⁵
• Regina Treudler³¹
• Ulrich Umpfenbach³²
• Christian Vogelberg³³
• Martin Wagenmann³⁴
• Anke Weißenborn³⁵
• Thomas Werfel³⁶
• Margitta Worm³⁷
• Helmut Sitter³⁸
• Eckard Hamelmann³⁹

Departments

• ¹ Airway Research Center North, University of Lübeck, Member of Deutsches Zentrum für Lungenforschung, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Schweiz,
• ² Institut für Allgemeinmedizin, University Medical Center Hamburg-Eppendorf, Hamburg, Deutschland,
• ³ Clinic for Gynecology and Obstetrics, St. Joseph-Krankenhaus Berlin-Tempelhof, Deutschland,
• ⁴ Children’s Hospital, University Hospital Frankfurt, Deutschland,
• ⁵ Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Deutschland,
• ⁶ HNO-Facharztpraxis, Eisleben, Deutschland,
• ⁷ HNO-Klinik, Klinikum rechts der Isar, Technical University of Munich, Munich, Deutschland,
• ⁸ Ökotrophologin, Journalistin, Idstein/Taunus, Deutschland,
• ⁹ Institut für Kinderernährung, Max Rubner-Institut, Karlsruhe, Deutschland,
• ¹ 
• ⁰ Kinderklinik, Universitätsklinikum Augsburg, Deutschland,
• ¹ 
• ¹ Klinik für Psychosomatik und Psychotherapie des UKGM, Universitätsklinik, Giessen, Deutschland,
• ¹ 
• ² Arbeitsgemeinschaft Dermatologiche Prävention e.V., Hamburg, Deutschland,
• ¹ 
• ³ Allergiezentrum Wien West, Wien, Österreich,
• ¹ 
• ⁴ Zentrum für Rhinologie und Allergologie, Wiesbaden, Deutschland,
• ¹ 
• ⁵ Integriertes Sozialpädiatrisches Zentrum, Dr. von Haunerschen Kinderspital, LMU Klinikum der Universität München, München, Deutschland,
• ¹ 
• ⁶ Abteilung für Stoffwechsel und Ernährung, Dr. von Haunersches Kinderspital, LMU Klinikum der Universität München, München, Deutschland,
• ¹ 
• ⁷ Kinder- und Jugendmedizin, Christliches Kinderhospital Osnabrück, Deutschland,
• ¹ 
• ⁸ Kinderzentrum Dresden-Friedrichstadt, Dresden, Deutschland,
• ¹ 
• ⁹ Schwerpunktpraxis für Allergologie und Lungenheilkunde im Kinder- und Jugendalter, Berlin, Deutschland,
• ² 
• ⁰ Ernährungsberatung und -therapie mit Schwerpunkt Allergologie, München, Deutschland,
• ² 
• ¹ Praxis für Kinder- und Jugendmedizin, Teltow, Deutschland,
• ² 
• ² Kinderarztpraxis, Bühl, Deutschland,
• ² 
• ³ Asthma- und Allergieambulanz, Dr. von Haunersches Kinderspital, LMU Klinikum der Universität, München, Deutschland,
• ² 
• ⁴ Allgemeine Pädiatrie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsmedizin Greifswald, Greifswald, Deutschland,
• ² 
• ⁵ Facharztpraxis für Kinder- und Jugendmedizin, Fulda, Deutschland,
• ² 
• ⁶ Kinder- und Jugendmedizin, Universitätsklinikum, Köln, Deutschland,
• ² 
• ⁷ Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich,
• ² 
• ⁸ Klinik für Geburtsmedizin, Vivantes Klinikum Neukölln, Berlin,
• ² 
• ⁹ Hochgebirgsklinik Davos, Schweiz,
• ³ 
• ⁰ Klinik für Pneumologie, Ruhrlandklinik, Westdeutsches Lungenzentrum am Universitätsklinikum, Essen, Deutschland,
• ³ 
• ¹ Klinik für Dermatologie, Venerologie und Allergologie, Leipziger Allergie-Centrum LICA – CAC, Universitätsmedizin, Leipzig, Deutschland,
• ³ 
• ² Praxis für Kinder- und Jugendmedizin, Dülken, Deutschland,
• ³ 
• ³ Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus an der Technischen Universität, Dresden, Deutschland,
• ³ 
• ⁴ HNO-Klinik, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland,
• ³ 
• ⁵ German Federal Institute for Risk Assessment, Berlin, Deutschland,
• ³ 
• ⁶ Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover, Hannover, Deutschland,
• ³ 
• ⁷ Klinik für Dermatologie, Allergologie und Venerologie, Campus Charité Mitte, Universitätsmedizin Berlin, Berlin, Deutschland,
• ³ 
• ⁸ Institut für Chirurgische Forschung, Philipps-Universität, Marburg, Deutschland, and
• ³ 
• ⁹ Kinder-Zentrum Bethel, Evangelisches Klinikum Bethel, Universitätsklinik für Kinder- und Jugendmedizin, Universitätsklinikum OWL, Universität Bielefeld, Bielefeld, Deutschland

Address

Prof. Dr. med. Matthias Kopp, Medizinbereich Kinder und Jugendliche, Insel Gruppe AG, Inselspital, ­Universität Bern, Freiburgstraße 15, 3010 Bern,
or
Prof. Dr. med. Eckard Hamelmann, Kinder-Zentrum Bethel, Evangelisches Klinikum Bethel, ­Universität ­Bielefeld, Burgsteig 13, 33617 Bielefeld
Email: [email protected]

Citation