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Li T, Zheng Q, Zhang M, Li Y, Zhou Y, Xu C, Zhang B, Wang Z, Tian J, Zhou L. How consistent are the key recommendations, and what is the quality of guidelines and expert consensus regarding paediatric cow's milk protein allergy? Eur J Pediatr 2024; 183:3543-3556. [PMID: 38809454 DOI: 10.1007/s00431-024-05622-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/10/2024] [Accepted: 05/19/2024] [Indexed: 05/30/2024]
Abstract
The objective of this study was to assess the quality and consistency of recommendations in clinical practice guidelines (CPGs) and expert consensus on paediatric cow's milk protein allergy (CMPA) to serve as a foundation for future revisions and enhancements of clinical guidelines and consensus documents. We conducted a comprehensive literature search across several databases, including the Chinese Biomedical Literature Database (CBM), PubMed, Embase, Web of Science, UpToDate, ClinicalKey, DynaMed Plus and BMJ Best Practice. We spanned the search period from the inception of each database through October 1, 2023. We integrated subject headings (MeSH/Emtree) and keywords into the search strategy, used the search methodologies of existing literature and developed it in collaboration with a librarian. Two trained researchers independently conducted the literature screening and data extraction. We evaluated methodological quality and recommendations by using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and AGREE-Recommendations for Excellence (AGREE-REX) tools. Moreover, we compared and summarized key recommendations from high-quality CPGs. Our study included 27 CPGs and expert consensus documents on CMPA. Only four CPGs (14.8%) achieved a high-quality AGREE II rating. The four high-quality CPGs consistently provided recommendations for CMPA. The highest scoring domains for AGREE II were 'scope and purpose' (77 ± 12%) and 'clarity of presentation' (75 ± 22%). The lowest scoring domains were 'stakeholder involvement' (49 ± 21%), 'rigor of development' (34 ± 20%) and 'applicability' (12 ± 20%). Evaluation with AGREE-REX generally demonstrated low scores across its domains. Conclusion: Recommendations within high-quality CPGs for the paediatric CMPA showed fundamental consistency. Nevertheless, the methodology and recommendation content of CPGs and the expert consensus exhibited low quality, thus indicating a substantial scope for enhancement. Guideline developers should rigorously follow the AGREE II and AGREE-REX standards in creating CPGs or expert consensuses to guarantee their clinical efficacy in managing paediatric CMPA. What is Known: • The quality of clinical practice guidelines and expert consensus on paediatric cow's milk protein allergy (CMPA) remains uncertain. • There is a lack of clarity regarding the consistency of crucial recommendations for CMPA management. What is New: • Improving the methodological quality of guidelines and consensus on CMPA requires greater emphasis on stakeholder engagement, rigorous development processes, and practical applicability. • The recommendations from four high-quality guidelines align. However, addressing clinical applicability, integrating values and preferences, and ensuring actionable implementation are critical to improving the quality of all guidelines.
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Affiliation(s)
- Tengfei Li
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qingyong Zheng
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Mingyue Zhang
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yiyi Li
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
| | - Yongjia Zhou
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
| | - Caihua Xu
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Bowa Zhang
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
| | - Zewei Wang
- First Clinical College of Medicine, Lanzhou University, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.
| | - Li Zhou
- Department of Gastroenterology, Gansu Province Maternity and Child Health Hospital (Gansu Province Central Hospital), Lanzhou, China.
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Zhang W, Wu Y, Pan C, Zhang X, Yan H, Zhang L. Ruptured giant omphalocele with congenital short small intestine: a case report. Front Nutr 2024; 11:1421033. [PMID: 39091686 PMCID: PMC11291450 DOI: 10.3389/fnut.2024.1421033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024] Open
Abstract
We herein present a case of a ruptured giant omphalocele with congenital short small intestine. Vacuum-sealing drainage and carboxymethylcellulose silver dressing promoted wound healing after repair, avoided abdominal compartment syndrome, and reduced the risks of multiple procedures. We review the perioperative management of omphaloceles in congenital short small intestines.
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Affiliation(s)
- Wenjing Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yang Wu
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Pan
- Department of Plastic, Aesthetic, Reparative and Reconstructive Surgery, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiangyun Zhang
- Department of Plastic, Aesthetic, Reparative and Reconstructive Surgery, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hong Yan
- Department of Plastic, Aesthetic, Reparative and Reconstructive Surgery, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Robert E, Al-Hashmi HA, Al-Mehaidib A, Alsarraf K, Al-Turaiki M, Aldekhail W, Al-Herz W, Alkhabaz A, Bawakid KO, Elghoudi A, El Hodhod M, Hussain AA, Kamal NM, Goronfolah LT, Nasrallah B, Sengupta K, Broekaert I, Domellöf M, Indrio F, Lapillonne A, Pienar C, Ribes-Koninckx C, Shamir R, Szajewska H, Thapar N, Thomassen RA, Verduci E, West CE, Vandenplas Y. Symptoms and management of cow's milk allergy: perception and evidence. FRONTIERS IN ALLERGY 2024; 5:1348769. [PMID: 38952569 PMCID: PMC11216524 DOI: 10.3389/falgy.2024.1348769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/18/2024] [Indexed: 07/03/2024] Open
Abstract
Introduction The diagnosis and management of cow's milk allergy (CMA) is a topic of debate and controversy. Our aim was to compare the opinions of expert groups from the Middle East (n = 14) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (n = 13). Methods These Expert groups voted on statements that were developed by the ESPGHAN group and published in a recent position paper. The voting outcome was compared. Results Overall, there was consensus amongst both groups of experts. Experts agreed that symptoms of crying, irritability and colic, as single manifestation, are not suggestive of CMA. They agreed that amino-acid based formula (AAF) should be reserved for severe cases (e.g., malnutrition and anaphylaxis) and that there is insufficient evidence to recommend a step-down approach. There was no unanimous consensus on the statement that a cow's milk based extensively hydrolysed formula (eHF) should be the first choice as a diagnostic elimination diet in mild/moderate cases. Although the statements regarding the role for hydrolysed rice formula as a diagnostic and therapeutic elimination diet were accepted, 3/27 disagreed. The votes regarding soy formula highlight the differences in opinion in the role of soy protein in CMA dietary treatment. Generally, soy-based formula is seldom available in the Middle-East region. All ESPGHAN experts agreed that there is insufficient evidence that the addition of probiotics, prebiotics and synbiotics increase the efficacy of elimination diets regarding CMA symptoms (despite other benefits such as decrease of infections and antibiotic intake), whereas 3/14 of the Middle East group thought there was sufficient evidence. Discussion Differences in voting are related to geographical, cultural and other conditions, such as cost and availability. This emphasizes the need to develop region-specific guidelines considering social and cultural conditions, and to perform further research in this area.
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Affiliation(s)
- E. Robert
- UZ Brussel, KidZ Health Castle, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - H. A. Al-Hashmi
- Pediatric Department, King Abdulaziz Hospital, Jeddah, Saudi Arabia
| | - A. Al-Mehaidib
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - K. Alsarraf
- Department of Pediatric Gastroenterology and Hepatology, Al Amiri Hospital (MOH), Kuwait City, Kuwait
- Department of Pediatric Gastroenterology and Hepatology, Dar Al Shefaa Hospital (PVT), Hawally, Kuwait
| | - M. Al-Turaiki
- Department of Pediatrics, King Salman Hospital, Riyadh, Saudi Arabia
| | - W. Aldekhail
- Section of Gastroenterology and Hepatology, Department of Pediatrics, King Faisal Specialist Hospital and 12 Research Centre, Riyadh, Saudi Arabia
| | - W. Al-Herz
- Department of Pediatrics, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - A. Alkhabaz
- Department of Pediatrics, Allergist & Clinical Immunology, Mubarak AlKabeer Hospital, Jabriya, Kuwait
| | | | - A. Elghoudi
- Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- CMHS, UAE University, Abu Dhabi, United Arab Emirates
| | - M. El Hodhod
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ali A. Hussain
- Department of Pediatrics, Al Adan and Al Salam International Hospitals, Kuwait City, Kuwait
| | - Naglaa M. Kamal
- Department of Pediatrics & Pediatric Hepatology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - L. T. Goronfolah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - B. Nasrallah
- Department of Pediatrics, American Hospital Dubai, Dubai, United Arab Emirates
| | - K. Sengupta
- Department of Pediatrics, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - I. Broekaert
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - M. Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - F. Indrio
- Department of Pediatric University of Salento, Lecce, Italy
| | - A. Lapillonne
- Neonatal Intensive Care Unit, Necker-EnfantsMalades Hospital, Paris University, Paris, France
- CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - C. Pienar
- Department of Pediatrics, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - C. Ribes-Koninckx
- Coeliac Disease and Gastrointestinal Immunopathology Research Unit, Hospital La Fe Research Institute Valencia, Valencia, Spain
| | - R. Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - H. Szajewska
- Department of Pediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - N. Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, QLD, Australia
- Department of Pediatrics, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - R. A. Thomassen
- Division of Pediatric and Adolescent Medicine, Department of Pediatric Medicine, Oslo University Hospital, Oslo, Norway
| | - E. Verduci
- Department of Pediatrics, Vittore Buzzi Children's Hospital University of Milan, Milan, Italy
| | - C. E. West
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Y. Vandenplas
- UZ Brussel, KidZ Health Castle, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Li Q, Deng Y, Xu Z, Zhou H. Combined transcriptomics and TMT-proteomics reveal abnormal complement and coagulation cascades in cow's milk protein allergy. Int Immunopharmacol 2024; 131:111806. [PMID: 38457985 DOI: 10.1016/j.intimp.2024.111806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/10/2024]
Abstract
Cow's milk protein allergy (CMPA) is primarily due to the inability of the intestinal mucosa to establish typical immunological tolerance to proteins found in cow's milk, and the specific molecular mechanism is still unclear. In order to investigate molecular alterations in intestinal tissues during CMPA occurrence, this study analyzed the jejunal tissue of β-lactoglobulin (BLG)-sensitized mice through transcriptomics and quantitative tandem mass tag (TMT)-labeled proteomics. A total of 475 differentially expressed genes (256 up-regulated, 219 down-regulated) and 94 differentially expressed proteins (65 up-regulated, 29 down-regulated) were identified. Comparing the KEGG pathways of the two groups, it was found that both were markedly enriched in the signaling pathways of complement and coagulation cascade. Among these, kallikrein B1 (KLKB1) in this pathway is speculated to be pivotal in CMPA. It may potentially enhance the release of bradykinin by activating the kallikrein-kinin system, leading to pro-inflammatory effects and exacerbating intestinal mucosal damage. This study suggests that the pathways of complement and coagulation cascades could be significant in the context of intestinal immunity in CMPA, and KLKB1 may be its potential therapeutic target.
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Affiliation(s)
- Qunchao Li
- Department of Pediatrics, Provincial Hospital Affiliated to Anhui Medical University, Hefei, China
| | - Yan Deng
- School of Medicine, Anhui University of Science and Technology, Huainan, China
| | - Zhiwei Xu
- Bengbu Medical College, Bengbu, China
| | - Haoquan Zhou
- Department of Pediatrics, Provincial Hospital Affiliated to Anhui Medical University, Hefei, China.
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Ribes-Koninckx C, Amil-Dias J, Espin B, Molina M, Segarra O, Diaz-Martin JJ. The use of amino acid formulas in pediatric patients with allergy to cow's milk proteins: Recommendations from a group of experts. Front Pediatr 2023; 11:1110380. [PMID: 37033186 PMCID: PMC10073469 DOI: 10.3389/fped.2023.1110380] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
One of the most common food allergies in children is cow's milk allergy (CMA). In breast-fed infants with CMA, the mother is encouraged to avoid dairy products. If this is not possible, or in formula fed infants, use of hypoallergenic replacement formulas such as extensively hydrolyzed formulas (EHF) is recommended. However, in ∼5% of patients EHFs are not tolerated and/or allergy symptoms can persist. When EHFs are ineffective and in severe forms of CMA, amino acid-based formulas (AAF) should be considered. Six pediatric gastroenterologists with extensive experience in food allergy management reviewed scientific publications and international clinical practice guidelines to provide practical recommendations on AAF. The guidelines reviewed had discrepancies and ambiguities around the specific indications for using formulas as a milk substitute. The panel recommends AAFs as the first therapeutic option in anaphylaxis due to CMA, in acute and chronic severe food protein-induced enterocolitis syndrome, in CMA associated with multiple food allergy, and in cases of eosinophilic esophagitis not responding to an extended exclusion diet or not eating solids. The main benefit of AAF is its absence of residual allergenicity, making it a safe treatment option in severe CMA patients who do not tolerate or respond to an EHF.
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Affiliation(s)
- Carmen Ribes-Koninckx
- Pediatric Gastroenterology, Hepatology and Nutrition La Fe University and Politechnic Hospital & La Fe Research Institute, Valencia, Spain
- Correspondence: Carmen Ribes-Koninckx
| | - Jorge Amil-Dias
- Emeritus, S. João University Hospital Center, Porto, Portugal
| | - Beatriz Espin
- Pediatric Gastroenterology and Nutrition Unit, Virgen del Rocio University Hospital, Seville, Spain
| | - Manuel Molina
- Department of Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | - Oscar Segarra
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan J. Diaz-Martin
- Pediatric Gastroenterology and Nutrition, Hospital Universitario Central de Asturias, Oviedo, Spain
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Connor F, Salvatore S, D’Auria E, Baldassarre ME, Acunzo M, Di Bella G, Farella I, Sestito S, Pensabene L. Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review. Nutrients 2022; 14:1317. [PMID: 35334974 PMCID: PMC8955686 DOI: 10.3390/nu14061317] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/02/2022] [Accepted: 03/17/2022] [Indexed: 12/11/2022] Open
Abstract
Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35-52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows' milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows' milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0-17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows' milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.
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Affiliation(s)
- Frances Connor
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children’s Hospital, Brisbane 4101, Australia;
- Mayne Academy of Pediatrics, Faculty of Medicine, University of Queensland, Brisbane 4101, Australia
| | - Silvia Salvatore
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy; (S.S.); (G.D.B.)
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.A.)
| | - Maria Elisabetta Baldassarre
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Miriam Acunzo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.A.)
| | - Gaia Di Bella
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy; (S.S.); (G.D.B.)
| | - Ilaria Farella
- Department of Biomedical Science and Human Oncology, Clinica Medica “A. Murri”, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Simona Sestito
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
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