一、母乳会不会导致食物过敏? 母乳是婴儿最天然、最理想的营养品,母乳喂养不仅为母亲及儿童带来很多健康益处,同时也具有重要的经济价值。虽然传统观念认为母乳中含有很多免疫成分,如sIgA、益生菌及低聚糖等,有利于婴儿免疫系统的成熟及降低过敏风险,然而亦有报道提示母乳可能与早期食物致敏有关[6-8]。
虽然母乳喂养婴儿发生食物过敏的概率很低,但仍有文献报道母乳可引起婴儿过敏症状,甚至是严重过敏反应。有学者采用皮肤点刺试验及母亲食物回避回加试验发现,在47例有症状的母乳喂养婴幼儿中 (1 ~ 19月龄),5例婴儿被确诊为“母乳”过敏 (10%),表现为当母亲进食特定食物后喂养婴儿后,婴儿出现特应性皮炎加重、风团、吐奶和喘息等症状;过敏原为牛奶、鸡蛋白和花生;而当母亲进行针对性饮食回避后,婴儿症状消失[9]。此项研究提示,母乳喂养亦可以发生食物过敏。
[17]。此外,还有母乳喂养后发生多种食物过敏的病例报道[18]。不仅如此,Monti等[19]还曾报道1例4月龄纯母乳喂养的过敏性疾病高危儿,当母亲进食鱼类后喂哺婴儿,导致婴儿发生严重过敏反应。
由此可见,纯母乳喂养婴儿亦可发生食物过敏,尤其是过敏疾病高危儿,应引起家长和医师的警惕。 二、母乳导致食物过敏的原因 食物过敏的免疫机制主要包括IgE和非IgE介导这2种类型,无论发病机制如何,食物抗原暴露是必要条件。越来越多的研究证实,婴儿可能在母亲子宫内或是通过母乳、呼吸道、污染的手或物体导致早期致敏。
研究显示,母亲摄入的膳食蛋白 (部分仍具有过敏原活性) 可以在母乳中检测到,婴儿可以通过母乳接触过敏原,因此哺乳被认为是导致婴儿早期致敏的途径之一。约50%的乳母可通过母乳分泌膳食抗原,浓度为0.1 ~ 1 000 ng / mL[20]。以牛奶为例,主要引起过敏症状的牛奶过敏原组分是酪蛋白、α乳球蛋白和β乳球蛋白,其中β乳球蛋白是研究最多的抗原。由于酪蛋白质和α乳球蛋白是母乳中的天然成分,但β乳球蛋白不会出现于人乳中[21],因而母乳中的β乳球蛋白来源于母亲食用的牛奶制品。53% ~ 63%食用牛奶的乳母乳汁中可检测出β乳球蛋白[22-24]。1项横断面研究在调查的3周内采集了10例健康母亲和10例特应质母亲的300份母乳样品,结果显示无论是在健康或是特应质母亲的乳汁中均可检测出β乳球蛋白[23]。婴儿可以因乳母食用牛奶或奶制品而通过母乳接触牛奶蛋白[25],从而发生牛奶蛋白过敏;当母亲单次摄入240 mL牛奶后,乳汁中检测出β乳球蛋白的持续时间可长达7 d[26]。因此,目前的过敏诊疗指南推荐,母乳喂养的牛奶蛋白过敏婴儿的母亲需要回避牛奶及奶制品,并补充钙剂[21,27-28]。 除牛奶外,59% ~ 74%的母乳中可检测出卵清蛋白[9],其浓度随母亲膳食中摄入鸡蛋量的增加而增加[29];48%的母乳中可检测出花生蛋白[9];此外,卵黏蛋白、α-S1-酪蛋白、小麦中的醇溶蛋白及其他食物过敏原也在生理状态下可从母乳中检测出来。
由此可见,母乳引起婴儿食物过敏的主要过敏原并不是母乳本身成分,而是母乳分泌的某些膳食成分,因此临床上更恰当的提法应为“经母乳导致的食物过敏”。 三、经母乳导致的食物过敏管理原则
牛奶蛋白诱发的过敏性直肠结肠炎是引起1 ~ 6月龄纯母乳喂养婴儿直肠出血 (出血可以是点状或大量) 的原因之一。过敏性直肠结肠炎病程自限,大多数婴儿在1岁内耐受牛奶。治疗的主要方法是回避可疑蛋白。对于母乳喂养婴儿,母亲回避牛奶蛋白通常可使症状于72 ~ 96 h消失;如果症状于72 ~ 96 h未缓解,可以考虑更换为深度水解蛋白配方,若仍然没有改善,可以更换成氨基酸配方[30-31]。 四、小结 综上所述,婴儿可以经母乳接触到过敏原从而引起食物过敏症状。当纯母乳喂养婴儿被确诊为食物过敏时,母亲针对性的饮食回避是治疗首选,同时应对母亲和婴儿进行营养和生长监测,减少母子双方发生营养不足的风险。 (文:重庆医科大学附属儿童医院 胡燕) 参考文献 1. Food allergy. World Allergy Organization. 2. Venter C, Patil V, Grundy J, et al. Prevalence and cumulative incidence of food 3. 陈静, 廖艳, 张红忠, 等. 三城市两岁以下儿童食物过敏现状调查[J]. 中华儿科杂志, 2012, 50(1):5-9. 4. Hu Y, Cheng J, Li H. Comparison of food allergy prevalence among Chinese infants in Chongqing, 2009 versus 1999[J]. Pediatr Int, 2010, 52(5):820-824. 5. Venter C, Pereira B, Voigt K, et al. Prevalence and cumulative incidence of food 6. Vadas P, Wai Y, Burks W, et al. Detection of peanut allergens in breast milk of lactating women[J]. JAMA, 2001, 285(13):1746-1748. 7. Cant A, Marsden RA, Kilshaw PJ. 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