REVISIÓN

 

Effect of the use of probiotics in the treatment of children with atopic dermatitis; a literature review

Efecto del uso de los probióticos en el tratamiento de niños con dermatitis atópica; revisión bibliográfica

 

 

Ingrid Pillar Nascimento da Costa Baptista¹, Elizabeth Accioly² and Patricia de Carvalho Padilha³

¹Nutritionist. Specialist in Clinical Nutrition. Instituto de Nutrição Josué de Castro (INJC). Universidade Federal do Rio de Janeiro (UFRJ-Federal University of Rio de Janeiro).
²Professor of the Departament of Nutrition and Dietetics from Instituto de Nutrição Josué de Castro (INJC). Universidade Federal do Rio de Janeiro (UFRJ-Federal University of Rio de Janeiro). Grupo de Pesquisa em Saúde Materna e Infantil (GPSMI-Research group in Maternal and Infant Health). Núcleo de Pesquisa em Micronutrientes (NPqM-Micronutrients Research Center).
³Professor of the Departament of Nutrition and Dietetics from Instituto de Nutrição Josué de Castro (INJC)-Universidade Federal do Rio de Janeiro (UFRJ-Federal University of Rio de Janeiro). Grupo de Pesquisa em Saúde Materna e Infantil (GPSMI-Research group in Maternal and Infant Health). Núcleo de Pesquisa em Micronutrientes (NPqM-Micronutrients Research Center).

Correspondence

 

 

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ABSTRACT

Introduction: Atopic dermatitis (AD) is a disease that mainly affects the pediatric population involving chronic and repetitive inflammatory skin manifestations. Its evolution is known as atopic march, which is characterized by the occurrence of respiratory and food allergies.
Aim: To carry out a classical review of the state-of-the-art scientific literature regarding the effect of probiotics on the treatment of children with AD.
Methods: Searches were conducted in Medline and Lilacs through the portals PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) and SciELO (http://www.scielo.br). There was a selection of the available publications in the period from 2001 to 2011, using the keywords atopic dermatitis and probiotics (in English and in Portuguese).
Results: After applying the inclusion and exclusion criterias, we selected 12 case-control studies which were conducted in four European countries and Australia. The methodological quality of the studies was assessed according to the STROBE recommendations. Assessment of agreement among researches in classifying the quality of the articles showed excellent agreement (k = 1.00, 95%) with a total of 9 papers at B level. The majority of the studies (75%) indicated a beneficial biological effect of probiotics on AD, including protection against infections, enhancement of the immune response, inflammation reduction and changes in gut the flora. The remaining studies showed no beneficial effects according to the outcomes of interest.
Conclusion: The majority of the studies in the scientific literature in this review showed improvements in some inflammatory parameters and in intestinal microbiota and not exactly, changes in clinical parameters. However, the biological effects observed in most of them suggest the possibility of benefits of the use of probiotics as an adjunvant in the treatment of AD.

Key words: Atopic dermatitis. Alergy. Probiotics.

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RESUMEN

Introducción: La dermatitis atópica (DA) es una enfermedad que afecta principalmente a la población pediátrica, la participación de crónica y repetitiva inflamatoria de la piel la evolución manifestaciones. Esto se conoce como marcha atópica, que se caracteriza por la aparición de alergias respiratorias y la alimentación.
Objetivo: Realizar una revisión sistemática de la literatura del estado de la técnica científica sobre el efecto de los probióticos en el tratamiento de niños con DA.
Métodos: Se realizaron búsquedas en Medline y Lilacs a través del PubMed portales (http://www.ncbi.nlm.nih.gov/PubMed/) y SciELO (http://www.scielo.br). Había una selección de las publicaciones disponibles en el período comprendido entre 2001 y 2011, con la dermatitis atópica palabras clave y los probióticos (en inglés y en portugués).
Resultados: Después de aplicar los criterios de inclusión y exclusión, se seleccionaron 12 estudios caso-control que se realizaron en cuatro países europeos y Australia. La calidad metodológica de los estudios se evaluó de acuerdo a las recomendaciones STROBE. Evaluación de un acuerdo entre los investigadores en la clasificación de la calidad de los artículos mostraron una excelente concordancia (k = 1,00, IC del 95%) con un total de 9 trabajos en el nivel B. La mayoría de los estudios (75%) indica un efecto beneficioso de los probióticos en DA, incluida la protección contra las infecciones, la mejora de la respuesta inmune, la reducción de la inflamación y cambios en la flora intestinal, la mejora de la condición clínica de la EA. Los estudios restantes no mostraron efectos beneficiosos de acuerdo a los resultados de interés.
Conclusión: La mayoría de los estudios en la literatura científica, en el período estudiado, mostró evidencia de beneficios en el uso de probióticos para controlar las manifestaciones clínicas de la DA, sin embargo el costo/ beneficio del tratamiento siempre debe ser evaluada.

Palabras clave: Dermatitis atópica. Alergia. Probióticos.

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Introduction

Atopic Dermatitis (AD) is considered a chronic inflammatory disease that affects the skin, and that can precede asthma and other allergic manifestations, sparking the Atopic March.¹ All age groups are affected, and among infants and children the acute form of the disease is predominant, with the presence of erythema, severe itching and oozing blisters that, in general, appear on the scalp, face and on the extending surfaces of the superior and inferior members.²

The pathogenesis of the disease is not fully understood, but studies indicate that the interaction between genetic and environmental factors leads to the development of the disease.³

It is estimated that the prevalence of the disease among children under four years old is approximately 14%.⁴ There are records indicating an increasing prevalence of the disease in the last three decades.⁵ According to Castro et al.⁶ about 50% of the patients present AD in the first year of life. The diagnosis of the disease is based on clinical criteria, as proposed by Hanifin & Rajka⁷, in 1980, which involves the patient's clinical history and physical examination of the affected regions. There are no specific laboratory tests for the detection of the disease.⁸

AD is classified according to degrees of severity based on the SCORAD index, which punctuates the extent and intensity of the dermatitis, the itching magnitude and the sleeping disturbances.⁹ The basic treatment for AD is to promote proper hydration of the skin and to control the inflamatory process with use of medications.⁶

Recently it was proposed that AD should be classified as intrinsic or extrinsic, according to its etiopathogenesis.¹⁰ Its extrinsic form, also known as allergic, affects 70 to 80% of patients, and is related to environmental, food and inhalant allergens sensitivity or high levels of IgE.¹⁰

Approximately 35% of children with moderate and severe forms of the disease have food allergies.¹¹ Food allergy is defined as an adverse reaction to non-toxic food and is a result of an exacerbated immunological response to protein components of food or preparation ingredients, recognized as food allergens, causing adverse health effects.¹²

The onset of food allergy may be due, among other factors, to the break of oral tolerance to the allergen. This strategy is of extreme importance to the body, because it promotes a balance between an anergic response and an effective response to strange agents.¹³ This is illustrated by the fact that, on a daily basis, we get in contact with a high number of foreign proteins that are absorbed without inflammatory signs of clinical importance and, on the other hand, the body fights pathogens which have the gastrointestinal tract as a gateway. According to Jacob et al.¹³ this process is based on nonspecific mechanisms and adaptive immunity, such as the gastric juice, peristalsis, epithelial barrier, intestinal microbiota, IgA secretion and action of regulatory T cells, allowing the recognition of antigens, but not the amplification of the response to them.

In the case of AD there is a dysfunction of the skin barrier, which normally acts as an important site of protection against environmental allergens, microorganisms and irritant substances.¹

Clinical evidence suggests that the use of probiotics in the treatment of AD improves the clinical status of patients.^14,15,16 Probiotics are defined as viable microorganisms that confer health benefits when administered in adequate amounts.¹⁷.

The present work aims to conduct a systematic review on the state-of-the-art scientific literature regarding the effect of probiotics on the treatment of children with AD.

 

Materials and methods

This work was conducted in the form of a classical review with the purpose of gathering and evaluating, judiciously, the main findings of the use of probiotics in the treatment of children aged from zero to five years old with AD.

The following steps were performed:

1. Identification of the work. Initially, there was a selection of the available articles in the scientific literature regarding the object under study. We used as bibliographic databases sources Medline and Lilacs through the portals PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) and SciELO (http://www.scielo.br), searching the available publications in the ten-year period of 2001 to 2011.

To perform the search work, the following keywords in English were used, atopic dermatitis and probiotics and, in Portuguese, dermatite atópica and probioticos.

In order to complement the discussion of the findings, textbooks and review articles about the subject were included in the study.

2. Preliminary assessment studies. The review was carried out following the steps of assessment proposed by The Cochrane Collaboration (www.cochrane.org).

Randomized clinical studies that employed probiotics in the treatment of children (interventional studies), from zero to five years old with AD were included in the analysis. Studies characterized as revisions, studies with animal, studies without a well defined methodology, summaries or "abstracts" and studies regarding other age groups, as well as, those using probiotics for prevention of AD were not included.

The results of bibliographic searches were screened, independently, by the main researcher and by other researchers by the titles of full publications and abstracts. After the identification of studies that met the criteria of the Cochrane Library, the complete publications selected were acquired and reviewed independently by the authors in order to determine the eligibility to the present study.

3. Assessment of methodological quality of work. The methodological quality of the included publications was assessed in accordance with the recommendations of the STROBE system (Strengthening the Reporting of Observational studies in Epidemiology),¹⁸ proposed by an international collaborative group composed of epidemiologists, statisticians, researchers and publishers of scientific journals involved in the dissemination of epidemiological studies (www.strobe-statement.org), with special consideration in the selection and detection of bias and follow up losses.

Three categories for quality assessment were established: A) when the study filled out more than 80% of the criteria set out in STROBE; B) when 50%-80% of the criteria were met; C) when less than 50% of the criteria were met. The correlation of quality evaluation between evaluators was again measured by results obtained with the quality scale, using the kappa coefficient calculation (k, IC 95%) and the differences were resolved by consensus.

Evaluation was done taking into account the opinion of two evaluators, reserving the opinion of the third author, for cases of results divergence.

4. Statistical analysis. The statistical analyses of the information were carried out using the statistical package SPSS version 17.0 for windows (Statistical Package for the Social Sciences). Assessment of the criteria of selection of studies and quality of studies between reviewers, followed the guidance of literature established for correlation measured by kappa: kappa < 0.10-absence of concordance, > 0.10 and < 0.40-weak, >0.40 and < 0.75-good agreement and 0.75 or more, an excellent agreement, being considered significant p values < 0.05.

 

Results

A total of 187 studies were found using the keyword "atopic dermatitis" and "probiotics" in both languages. Studies carried out in Brazil or in Portuguese language were not found. After applying inclusion and exclusion criterias, 12 publications were selected, all as case control, held in 4 European countries and in Australia.

Regarding the analysis of the methodological quality of the work, Kappa coefficient (IC 95%) was estimated, considering the opinion of 2 researchers independently. The independent inclusion selection of studies for this review of literature presented an excellent concordance agreement (k = 1.00, CI 95%) between the evaluators, not being necessary the intervention of a third one, with a total of 9 papers with B classification (75%), 2 classified as C (16.6%) and 1 categorized as A (8.4%). In view of the reduced number of selected works, we decided to keep all of them in the final analysis (table I). It should be highlited that despite evaluating a total of 12 articles, this review covers only 9 case studies, because this same sample was used in three articles and another sample in two articles. Importantly, despite a total of 12 articles reviewed, this review covers only 9 case series, because the same sample was used in three articles^11,15,22 and another, in two articles.^23,24

Only 25% of the articles analyzed (n = 3) did not describe follow-up losses. Among the articles that reported losses, variation was among 3.77%²⁶ to 42.6%²⁴ of the studied sample. As methodological limitations of the studies, reduced sample size,^20,27 flaws in randomization process²⁴ and small number of bacterial groups analyzed were reported.²⁷

The significant majority of the articles included children from zero to two years old and only one of them studied children between two and five years old.⁵ The description of the circumstances and goals of the selected studies, inclusion and exclusion criteria and methods employed are presented in table II and in table III.

 

 

 

 

The primary outcomes studied included improvement of the clinical signs,^{5,15,20,21,22,26} allergy modulation,¹⁹ impact on the immune system^17,22,25 and on the intestinal^17,19,20,27 and skin microbiotas,¹⁷ in addition to the effects on the fecal²³ and plasma²⁴ markers of inflammation.

Studies by Weston et al. 2005²¹ and Prescott et al. 2005²² deal with different outcomes, but refer to the same samples. The same occurs in the studies by Viljanen et al. 2005a¹⁵, Viljanen et al. 2005b²³ and Viljanen et al. c 2005.²⁴

The severity of AD was evaluated through SCORAD in all selected articles. The studies included cases of mild,^19,20 mild to moderate^26,27 and moderate to severe severity.^5,21,22 All degrees of severity were included in 41% of the articles.^{15,17,23,24,25}

The analyzed studies included several strains of probiotics, Lactobacillus rhamnosus GG;^{5,15,17,20,23,24,26} Lactobacillus rhamnosus;²⁵ Lactobacillus GG;²⁵ Lactobacillus fermentum VRI-033 PCC;^21,22 Lactobacillus acidophilus-NCFM;²⁷ a mix of probiotics containing Lactobacillus rhamnosus GG, Lactobacillus LC705 rhamnosus, Bifidobacterium breve Bbi99 and Propionibacterium freudenreichii SSP JS;^15,23,24 and also Bifidobacterium lactis Bb12 strains¹⁹ and Bifidobacterium lactis Bi-07.²⁷

Probiotic supplementation was done through the administration of capsules^{5,15,23,24,26,27} or sachets^21,22 diluted or mixed into non-specified food,^15,23,24 milk^5,26 or water.^21,22,26 Some articles described studies in which the probiotics were previously added to extensively hydrolyzed casein formula,¹⁷ to extensively hydrolysed milk formula ^19,20,25 or to amino acid based formula.¹⁹

Studies presented the offered dose of probiotics in colony-forming units (CFU). The most used concentration of probiotics in studies employing capsules was of 5 x 10⁹cfu^{5,15,23,24,26}, but concentrations of 2x10⁸cfu^15,23,24 and 10¹⁰cfu²⁷ were also administrated. Among these studies only the one by Larsen et al.²⁷ did not report the amount of daily doses consumed by the participants, however the other studies stated an administration of twice a day.^{5,15,23,24,26} The dose mentioned in two studies using sachets^21,22 was of 1 x 10⁹cfu, twice a day. The studies in which supplementation was done through milk formulas containing previously added probiotics, reported a concentration of colony-forming units per gram reaching 1 x 10⁹ cfu/g^19,20 and 3 x 10⁸ cfu/g.²⁵ Nermes et al. 2010¹⁷ high-lighted that to achieve a daily consumption of 3.4 x 10⁹ cfu, it was necessary to supplement 5.0 x 10⁷ cfu/g.

The probiotic administration period was of four,^15,23,24 eight,^{5,20,21,22,26} and twelve^17,25,26 weeks, with an average of 7.4 weeks of supplementation. There is no information about the period of use of probiotics in the study by Kirjavainen et al. 2002¹⁹.

Allergy cases have been reported in all analyzed studies in this review and the prevalence ranged from 35.8%¹⁷ to 77%²¹ of the studied samples. Allergy to cow's milk, egg, wheat, peanut, codfish, cereal/gliadin were the types of food allergy studied and identified by allergy skin tests or laboratory tests. Nevertheless, the identification of which specific food item was related to the allergy symptoms occured only in Kirjavainen et al.²⁰ .

The main results and conclusions of the studies are presented in table IV.

 

 

The majority of the selected studies showed beneficial effects of probiotics supplementation,^{15,17,19,20,21,22,23,24} however some studies found no evidence of a positive impact of supplementation on the outcomes of interest related to AD.^5,25,26,27

 

Discussion

Although there is no available data about the prevalence of AD in Brazil concerning the age group studied, estimates performed in other countries indicate that the occurrence of the problem is not negligible. In addition to the clinical implications that contribute to overload the costs in the health sector (hospitalization and health team support), there are indirect costs (pain, suffering, impact on the quality of life and on the professional and education environment). Mancini et al.²⁸ revised the costs concerning AD in the United States and demonstrated that direct national expenditure ranged from 364 million dollars to 3.8 billions dollars, with an annual spending per patient ranging from $ 167 to $ 580.

A study conducted by Verboom et al.²⁹ found variations in the cost of treatment per patient, ranging around $ 71 dollars in the Netherlands and reaching $ 2559 dollars in Germany. The authors attributed the discrepancy in the results to the variation of population studied (inpatient versus outpatient) and to the different severity levels of AD observed. The more severe cases require more expensive treatments, due to the need for more expensive medications and special care. It was also pointed out that the household expenses are high, because the health system does not cover all the needs required by these patients.

We must highlight that the selected studies were concentrated in the Nordic countries. This region, with continental temperate climate, reaches extremely cold temperatures during winter. Weiland et al.³⁰ suggested that the weather can interfere in the prevalence of asthma and AD. Data from Weiland's study indicated that the prevalence of AD symptoms are positively associated with latitude (the higher the latitude, i.e. more distant from the line of Ecuador, the higher the level of symptoms) and negatively associated with the annual average temperature (locations with lower temperatures are associated with higher intensity of symptoms). The authors still claim that such impacts act indirectly, since they promote behavioral changes and also because inhabitants of these regions have a reduced exposure to sunlight. Byremo et al.,³¹ studying Norwegian children, found that exposure to sunlight provides positive results in treating AD due to the immuno suppressor effect of ultra violet radiation. There are also reports of clinical symptoms worsening in regions of intense heat,³² due to heat intolerance, excessive sweating³³ and greater exposure to pollen.³⁴

Other environmental factors considered determinant to AD are related to changes in lifestyle. Industrialized and developed countries, as those of Western Europe and the United States, were regarded as places of greater prevalence of allergic diseases, but it has been demonstrated an increase in developing countries, what may be due to the urbanization process, greater exposure to pollutants,³⁵ as well as changes in the dietary pattern.³⁶

In Brazil only the studies carried out by Camelo-Nunes et al.² and Solé et al.³² assessed the prevalence of AD, but in another age group. Both researches encompassed children and adolescents, from 6 to 7 and 13 to 14 years old, respectively, following the protocols established by ISAAC (International Study of Asthma and Allergies in Childhood).³⁷ The first study, which involved data from a Brazilian city, detected a medical diagnosis prevalence for AD of 13.2% to 13.4% in children and adolescents. The study by Solé et al.,³² as part of the multicenter study previously cited, found variations in prevalence, from 7.9% to 15.4% in children, and 2.2% to 14.2% among young people and found that the South of the country has the highest prevalence of severe cases of the disease.

In this review the significant majority of works included children from zero to two years old. Bieber³⁸ indicated that 60% of AD cases begin in the first year of life and 85% of all cases occur before the age of five. Illi et al.³⁹ showed that 43.2% of children with early onset (less than two years old) reach complete remission of symptoms at the age of three. However, the study points out that 38% of people develop the intermittent form, in which symptoms are recurring. The study also makes reference to cases that persist until adulthood.

It should be highligthed that in the age group of zero to two years old there is an establishment of the intestinal microbiota of the individual, which depends on various internal and external factors of the host, such as type of delivery, breastfeeding and diet, in addition to the medications used. At the age of two the intestinal microbiota of the child reaches the characteristic profile of adults.⁴⁰

Several studies demonstrate that the presence of this set of intestinal microorganisms is an important factor that raises the maturation of the immune system, by providing stimulus to the synthesis of cytokines and antigen-presenting cells.¹³ Works have showed that rats raised in free conditions of germs do not develop oral tolerance and their immune system does not reach maturity, however this can be reverted if they receive Bifidobacterium supplementation.⁴¹

Damião et al.⁴⁰ point out that intestinal microbiota promotes a "physiological" inflammation state, delicately controlled, allowing the immune system to respond differently to pathogenic bacteria and to autologous agents.

The human gut microbiota is formed by Bifidobacteria, Lactobacillus and other bacterium, including pathogenic species. The dominant flora keeps the others under its control, but food, environmental changes and the use of antibiotics can distort the balance between them.⁴² Collado et al.⁴³ claim that when there is a disruption in the harmony between host and microbiota, diseases may arise. This event is known as dysbiosis,⁴³ and diseases that may be related to this condition are inflammatory bowel disease, antibiotic associated diarrhea and allergies.⁴²

Bifidobacteria are identified as key components for proper immune system stimulation and homeostasis of gastrointestinal tract mucosa.¹³ Reports state that the intestinal microflora of atopic children is differentiated from those who are not allergic, containing higher levels of Clostridium and lower levels of Bifidobacterium^41,45 species. This discrepant composition precedes the development of atopy⁴⁶ and the modulation of the microenvironment can promote clinical improvement of pediatric patients with AD.¹³ It is proposed as positive effects of the use of probiotics in AD, the stabilization of the intestinal barrier, the modulation of the response to antigens via regulatory T cell through the reduction of Th2-type cytokines expression and an increase in the production of IL-10 and TGF-β. In addition, it also increases the production of IgA in the gut.⁵ Such evidence could justify the favourable effects of the use of probiotics in situations in which the integrity and/or functionality of the intestinal barrier is affected, as it occurs in cases of atopy. All selected studies in this review state clinical records of some kind of allergy (food or other types of allergy).

The significant majority of probiotics used were related to microbiota of healthy individuals (species of Bifidobacteria and Lactobacillus). In this review the strain Lactobacillus rhamnosus GG was employed in half of the studies.^{5,15,17,20,23,24,26} This strain is related to the control of infectious diarrhea and diarrhea associated with antibiotics.⁴⁷ Bezirtzoglou & Stavropoulou⁴⁸ point that it is still unknown which would be the most indicated bacterial strain for the promotion of a proper intestinal barrier function, indicating the need for further studies on this subject.⁴⁸

It was observed variations in doses, time and forms of administration of probiotics. Kirjavainen et al.¹⁹ were the only ones to take into consideration as reference dose the concentrations used in studies on the use of probiotics in the treatment of children with diarrhea. However, a recent revision by Cochrane indicated a dosage over five billion cfu⁴⁹ for diarrhea prevention, which would represent 5 times the dose used in the study. This finding demonstrates that there is still controversy over the optimal dose.

It should also be highlighted that children under two years old have an immature immune system. The positive effects of probiotics supplementation on the immune system of pediatric pacients was addressed in this review,^22,24,25 and only the study carried out by Brower et al.²⁵ did not detect benefits over immunity.

Kirjavainen et al.,¹⁹ Nermes et al.¹⁷ and Larsen et al.²⁷ discoursed on the effect of probiotics supplementation on intestinal microbiota composition and only one of them showed positive impact on microbiota.¹⁹

Some of the studies in this review presented, as a primary outcome, the improvement of the patient's clinical status. The improvement of the patient's clinical status was presented, by their authors, as a primary outcome in some of the studies of this review.^{5,15,20,21,26}. A reduction in the severity of AD was found,^20,21 primarily for children with food or environmental sensitivity.¹⁵ However the works of Fölster-Holst et al.⁵ and Grüber et al.²⁶ found no evidence of effectiveness on the use of probiotics with that purpose, but indicate the need for further studies regarding this subject.⁵

Illi et al.³⁹ consider that the prognosis is determined mainly by the severity and by the presence of atopic sensitivity. Approximately 35% of children with moderate and severe forms of the disease have food allergies.¹¹ It was noticeable that cases of allergy were present in all studies. Due to the fact that many researches did not demonstrate the results of food and environmental allergens analyses separately and did not submit results to different isolated types of food, it was not possible to have a basis for comparison. Only in the study conducted by Kirjavainem et al.²⁰ it was observed that 41% of the population had food allergy, identifying cow's milk, egg and wheat as the causes of allergy.

Regarding cow's milk allergy, which was identified by double blind placebo controlled tests, indexes varied between 8%²⁵ to 57%.^{15,19,20,24,25}

Nonetheless, Gerasimov et al.¹⁶ noted that children with allergy to cow's milk (CM) may not have success in supplementation with Lactobacillus, because the necessary culture medium for probiotic growth contains milk. As a result, traces of milk can be present in the composition of the preparation containing this specific strain even after being industrially processed. Only Brouwer et al.²⁵ reported that the studied probiotics culture medium consisted of an extensively hydrolysed milk formula.

The basic treatment for allergies is to avoid contact with irritants and allergens.^5,50 Rancé⁵¹ notes the importance of early detection and management of allergies because, frequently, people are subjected to unnecessary food restrictions. Considering the critical moment of growth and development of children, it is imperative that appropriate food guides must be adopted, bearing in mind the appropriate amount of nutrients.^50,52 It is noteworthy that, in cases of moderate to high severity of AD, the injury in the skin as well as the chronic inflammatory state, characteristic of the disease, may increase protein and energy requirements.⁵³

Researches indicates that there is risk of nutritional disorders in children, including low weight and malnutrition.⁵⁴ The severity of the nutritional disorder is directly related to the number of food items to which the child presents sensitivity.⁵⁰

The type of newborn feeding greatly influences their exposure to antigens. Verhasselt⁵⁵ points out that children fed with cow's milk only receive this type of antigen. Children, who are breastfed, come into contact with a diversity of antigens that have been ingested and processed by the mother's gastrointestinal tract, but with reduced allergenic potential, which contributes to the promotion of oral tolerance. In addition to this, breastfeeding permits a transfer of prebiotics, IgA, IgG, lysozyme, lactoferrin and other protective factors,⁵⁵ as well as non-pathogenic bacteria, collaborating with the newborn gut colonization.⁵⁶

Kull et al.⁵⁷ indicated that exclusive breastfeeding for four months or more, decreases the risk of developing AD in the first four years of life, regardless of the child's family allergy history. The study also demonstrated an inverse relationship between early and transitory forms of AD (before two years old) as well as in early and persistent forms and breastfeeding (OR 0.76, 95% CI 0.58;, -0.99; and OR, 0.59; 95% CI 0.45, -0.77, respectively). Laubereau et al.⁵⁸ also pointed out breastfeeding as a protective factor for the development of the disease.

Due to the numerous benefits of breastfeeding, it is highly recommended for children coming from families with a history of atopy.^{35,55,57,58,59}

Bosguniewiczet al.⁶⁰ highlight the importance of a nutritionist in the treatment of children with AD, exercising a fundamental role in the evaluation of diets consumed by them, as well as guidance to parents and guardians about the food that should be offered to these children.

Based on the foregoing it is concluded that the intestinal microbiota of atopic children is different from that found in healthy children. However, there are controversies about the widespread use of this alternative therapy in children with AD. It seems that children who have greater benefit are those with a history of food allergies.

Analyzing the works included in this review, most studies showed improvements in parameters of inflammatory intestinal microbiota and not exactly, changes in clinical parameters, what does not allow us to state that the use of probiotics in AD produces clinical effects, relieving symptoms. However, the biological effects observed in most of them suggest the possibility of benefits of the use of probiotics as an adjunct in the treatment of AD, regarding the immunological aspects and gastrointestinal microenvironment, especially in cases associated with food allergy.

 

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Correspondence:
Ingrid Pillar Nascimento de Costa Baptista.
Instituto de Nutrição Josué de Castro.
Centro de Ciéncias da Saúde.
Universidade Federal do Rio de Janeiro.
E-mail: ipillar@ig.com.br

Recibido: 2-VIII-2012.
1.^a Revisión: 27-IX-2012.
Aceptado: 23-X-2012.