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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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Nocerino R, Carucci L, Coppola S, Oglio F, Masino A, Agizza A, Paparo L, Berni Canani R. The journey toward disease modification in cow milk protein allergy. Immunol Rev 2024. [PMID: 39046826 DOI: 10.1111/imr.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Cow milk protein allergy (CMPA) is one of the most common food allergies in the pediatric age worldwide. Prevalence, persistence, and severity of this condition are on the rise, with a negative impact on the health-related quality of life of the patients and families and on the costs related to its management. Another relevant issue is that CMPA in early life may be the first stage of the "allergic march," leading to the occurrence of other atopic manifestations later in life, especially asthma, atopic eczema, urticaria, and rhinoconjunctivitis. Thus, "disease modification" options that are able to modulate the disease course of pediatric patients affected by CMPA would be very welcomed by affected families and healthcare systems. In this review, we report the most relevant progress on this topic.
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Affiliation(s)
- Rita Nocerino
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Laura Carucci
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Serena Coppola
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Franca Oglio
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Antonio Masino
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Alessandra Agizza
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
| | - Lorella Paparo
- Department of Laboratory Medicine, ASL Benevento, Benevento, Italy
| | - Roberto Berni Canani
- Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
- ImmunoNutritionLab at CEINGE Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
- European Laboratory for the Investigation of Food-Induced Diseases, University of Naples Federico II, Naples, Italy
- Task Force for Microbiome Studies, University of Naples Federico II, Naples, Italy
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Du X, Yin S, Wang T, Chu C, Devahastin S, Yi J, Wang Y. Identification of proteolytic bacteria from Yunnan fermented foods and their use to reduce the allergenicity of β-lactoglobulin. J Dairy Sci 2024:S0022-0302(24)01006-3. [PMID: 39004134 DOI: 10.3168/jds.2024-25055] [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: 04/16/2024] [Accepted: 06/17/2024] [Indexed: 07/16/2024]
Abstract
Beta-lactoglobulin (β-LG) is considered to be the major allergenic protein in milk. Lactic acid bacteria (LAB) possess a protein hydrolysis system that holds great promise for hydrolyzing β-LG and reducing its allergenicity. Therefore, this study aimed to screen LAB with β-LG hydrolysis activity from Yunnan traditional fermented foods. The results showed that Pediococcus pentosaceus C1001, Pediococcus acidilactici E1601-1, and Lactobacillus paracasei E1601-2, could effectively hydrolyze β-LG and further reduce its sensitization (more than 40%). All 3 lactic acid bacteria hydrolyzed β-LG allergenic fragments V41-K60 and L149-I162. Moreover, they encode a variety of genes related to proteolysis, such as aminopeptidase pepC and pepN, proline peptidase pepIP and endopeptidase pepO, and L. paracasei E1601-2 contains extracellular protease coding gene prtP. And they encode a variety of genes associated with hydrolyzed proteins. The 3 strains screened in this study can be used to develop hypoallergenic dairy products.
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Affiliation(s)
- Xiang Du
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming 650500, China; Yunnan Engineering Research Center for Fruit & Vegetable Products, Kunming 650500, China; International Green Food Processing Research and Development Center of Kunming City, Kunming 650500, China; Yunnan International Joint Laboratory of Green Food Processing, Kunming 650500, China
| | - Shulei Yin
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming 650500, China; Yunnan Engineering Research Center for Fruit & Vegetable Products, Kunming 650500, China; International Green Food Processing Research and Development Center of Kunming City, Kunming 650500, China; Yunnan International Joint Laboratory of Green Food Processing, Kunming 650500, China
| | - Tao Wang
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming 650500, China; Yunnan Engineering Research Center for Fruit & Vegetable Products, Kunming 650500, China; International Green Food Processing Research and Development Center of Kunming City, Kunming 650500, China; Yunnan International Joint Laboratory of Green Food Processing, Kunming 650500, China
| | - Chuanqi Chu
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming 650500, China; Yunnan Engineering Research Center for Fruit & Vegetable Products, Kunming 650500, China; International Green Food Processing Research and Development Center of Kunming City, Kunming 650500, China; Yunnan International Joint Laboratory of Green Food Processing, Kunming 650500, China
| | - Sakamon Devahastin
- Advanced Food Processing Research Laboratory, Department of Food Engineering, Faculty of Engineering, King Mongkut's University of Technology Thonburi, Bangkok 10140, Thailand
| | - Junjie Yi
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming 650500, China; Yunnan Engineering Research Center for Fruit & Vegetable Products, Kunming 650500, China; International Green Food Processing Research and Development Center of Kunming City, Kunming 650500, China; Yunnan International Joint Laboratory of Green Food Processing, Kunming 650500, China
| | - Yanfei Wang
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming 650500, China; Yunnan Engineering Research Center for Fruit & Vegetable Products, Kunming 650500, China; International Green Food Processing Research and Development Center of Kunming City, Kunming 650500, China; Yunnan International Joint Laboratory of Green Food Processing, Kunming 650500, 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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5
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Vandenplas Y, Broekaert I, Domellöf M, Indrio F, Lapillonne A, Pienar C, Ribes-Koninckx C, Shamir R, Szajewska H, Thapar N, Thomassen RA, Verduci E, West C. An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy. J Pediatr Gastroenterol Nutr 2024; 78:386-413. [PMID: 38374567 DOI: 10.1097/mpg.0000000000003897] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/25/2023] [Indexed: 07/27/2023]
Abstract
A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Flavia Indrio
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France
- CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Corina Pienar
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Gastroenterology and Hepatology & Instituto de Investigacion Sanitaria, La Fe University Hospital, Valencia, Spain
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rut Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Christina West
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Vandenplas Y, Meyer R, Nowak-Wegrzyn A, Salvatore S, Venter C, Vieira MC. The Remaining Challenge to Diagnose and Manage Cow's Milk Allergy: An Opinion Paper to Daily Clinical Practice. Nutrients 2023; 15:4762. [PMID: 38004156 PMCID: PMC10675216 DOI: 10.3390/nu15224762] [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: 10/16/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Guidelines and recommendations for the diagnosis and management of cow's milk allergy (CMA) in childhood are based on scientific review of the available evidence. While this approach is the most rigorous, guidelines may not fully address all scenarios encountered by clinicians. Many symptoms of CMA overlap with other common childhood illnesses and are subjectively reported by the caregivers of the infant, as is the interpretation of the dietary interventions. Additionally, many healthcare professionals and caregivers do not follow the recommendations to perform an oral food challenge or reintroduction of cow's milk after a diagnostic elimination diet because (1) the infant is doing well and (2) the carer's fear of symptoms relapsing with this procedure. As a result, CMA in infants may be either under-diagnosed leading to reduced quality of life for families or over-diagnosed, resulting in unnecessary long-term elimination diets and increasing the risk for nutritional deficiencies. This paper discusses some of these controversial topics, focusing on misdiagnosis and mismanagement in clinical practice. The lack of objective diagnostic criteria can hamper the diagnosis and management of CMA in daily practice.
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Affiliation(s)
- Yvan Vandenplas
- UZ Brussel, KidZ Health Castle, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
| | - Rosan Meyer
- Department Paediatrics, Imperial College London, London SW7 2BX, UK
- Department Dietetics, Winchester University, Winchester SO23 4NR, UK
- Department Medicine, KU Leuven, 3001 Leuven, Belgium
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children’s Hospital, New York, NY 10016, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Silvia Salvatore
- Department of Pediatrics, Hospital “F. Del Ponte”, University of Insubria, 21100 Varese, Italy;
| | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, University of Colorado, Aurora, CO 80045, USA
| | - Mario C. Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba 80250, Brazil;
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El-Asheer OM, El-Gazzar AF, Zakaria CM, Hassanein FA, Mohamed KA. Frequency of gastrointestinal manifestations among infants with cow’s milk protein allergy, Egypt. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2022. [DOI: 10.1186/s43054-022-00128-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Abstract
Background
Cow’s milk is known to be the most frequent food allergen in infants in the first years of life. Eliminating cow milk protein from diets and reintroducing it with a challenge test are the main methods for sure diagnosis. Cow’s Milk-related Symptom Score (CoMiSS) has been developed for primary health care providers to improve their knowledge about CMPA.
Objective
This study was conducted to prescribe clinical presentation of cow’s milk allergy among infants.
Methods
A cross-sectional study was conducted at Gastroenterology and Nutrition Unit, University Children Hospital, from the 1st of January 2020 to the 31st of December 2020. Forty infants, complaining of recurrent or persistent gastrointestinal manifestations, were included in our study (28 males and 12 females). Those infants were subjected to detailed medical and social patient history, comprehensive physical exam, and CoMiSS scoring as an awareness tool to suspect underlying cow milk allergy. Infants with a CoMiSS of more than 12 points and positive elimination rechallenge test were regarded as eligible to be part of our study.
Results
This study showed that the most frequently occurring gastrointestinal manifestations associated with CMPA were regurgitation (92%), diarrhea (80%), colic (75%), vomiting (67.5%), and lastly constipation which represents only (5%).
Conclusion
Regurgitation and diarrhea are the commonest presentations for infants proved to have cow milk allergy with CoMiSS score and elimination rechallenge test, where constipation is the least common presentation for those infants.
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Characteristics of cold plasma treatment and enzymatic hydrolysis on IgG/IgE-binding ability of β-lactoglobulin. FOOD BIOSCI 2022. [DOI: 10.1016/j.fbio.2022.102161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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9
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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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10
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Suleyman A, Tamay Z, Güler N. Risk Factors for the Development of IgE-Mediated Food Allergy in Preschool Children with Asthma. J Trop Pediatr 2022; 68:6533389. [PMID: 35188210 DOI: 10.1093/tropej/fmac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Food allergy is a component of the atopic march and may have effects on asthma. This study aimed to evaluate the risk factors for confirmed immunoglobulin E-mediated food allergies and their impact on the clinical picture in preschool children with asthma. METHODS Clinical history and allergic assessment results were obtained from medical records and analyzed retrospectively. Preschool children with asthma were included in the study and the characteristics of food allergy and asthma were evaluated. The patients were grouped as those with food allergy (Group I, n = 60) and those without (Group II, n = 98). RESULTS In patients with food allergy and asthma, the number of episodes requiring systemic steroids in the last year (p = 0.002), atopic dermatitis (p = 0.001), parental atopic disease (p = 0.009) and aeroallergen sensitivity rates (p < 0.001) was higher than patients without food allergies. The use of medium or high doses of inhaled steroids to achieve asthma control was more frequent in patients with food allergies (p = 0.014). Parental history of atopic disease [p = 0.007, odds ratio (OR): 3.27, 95% confidence interval (CI) 1.37-7.77)], atopic dermatitis (p = 0.017, OR: 2.80, 95% CI: 1.19-6.57), starting complementary food after 6 months (p = 0.004, OR: 3.9, 95% CI: 1.5-10.0) and having aeroallergen sensitivity (p < 0.001, OR: 6.01, 95% CI: 2.21-16.29) were identified as significant risk factors for food allergy. CONCLUSION Asthmatic preschool children with food allergies are more likely to have a parental atopic disease, atopic dermatitis, aeroallergen sensitivity and starting complementary food after 6 months. These patients experience more asthma attacks and need higher doses of steroids.
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Affiliation(s)
- Ayse Suleyman
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeynep Tamay
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nermin Güler
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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11
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Baghlaf MA, Eid NMS. Prevalence, Risk Factors, Clinical Manifestation, Diagnosis Aspects and Nutrition Therapy in Relation to both IgE and IgG Cow’s Milk Protein Allergies among a Population of Saudi Arabia: A Literature Review. CURRENT RESEARCH IN NUTRITION AND FOOD SCIENCE JOURNAL 2021. [DOI: 10.12944/crnfsj.9.2.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cow milk protein allergy (CMPA) becoming a major public health issue that has attracted the attention of health professionals and researchers. This paper aimed to review the important aspects of both IgE and IgG types of cow’s milk protein allergy in terms of prevalence, clinical manifestation, risk factors, other health-related issues and nutritional therapy proposed for such allergies in the adult and pediatric population in Saudi Arabia. A search on “cow’s milk allergy” was done using PubMed, Google Scholar and Scopus Engine for published papers between 1993 and 2020 to find studies yielding knowledge on that context. The prevalence of cow’s milk protein allergy (CMPA) among infants is now in the range of 2–3%. This type of allergy is also detected in adulthood but less frequently. CMPA is defined as an immunological reaction to specific proteins in milk. CMPA is classified based on its type as an immunoglobulin E (IgE)-mediated form and an immunoglobulin G (IgG)-mediated form, each type representing different immunological pathways. The presence of Genetic aspects, family history and short duration of breastfeeding in the infant are among the risk factors contributing to this form of allergy. Its manifestations mainly present as skin presentation, followed by the gastrointestinal and respiratory presentation in most cases in addition to a life-threatening anaphylactic reaction that may occur in 12% of cases. food allergy committees have developed strict diagnosis criteria, including blood testing for food-specific immunoglobulin E (sIgE), a skin prick test and double-blind placebo-controlled food challenges (DBPCFC) as the gold standard. A diet free of cow’s milk protein (CMP) allergen and including the appropriate alternative milk formula is the first line of prevention recommended by many organizations and food allergy experts. As for Saudi Arabia, more research and clinical trials are required to discuss the various aspects of adult and pediatric CMPA and to provide a better understanding along with good control strategies implementation.
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Affiliation(s)
- Mashail A Baghlaf
- 1Faculty of Applied Medical Sciences, Department of Medical Laboratory Technology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Noura M S Eid
- 2Faculty of Applied Medical Sciences, Department of Clinical Nutrition, King Abdulaziz University, Jeddah, Saudi Arabia
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12
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Berktas M, Kirbiyik F, Aribal E, Aksit A, Altintas DU. Treatment Options for Cow's Milk Protein Allergy: A Modeling Analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:307-315. [PMID: 32606847 PMCID: PMC7306455 DOI: 10.2147/ceor.s242021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/18/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Cow's milk protein allergy (CMPA) is one of the most common food allergies in early childhood. We aimed to evaluate clinical and economic outcomes of the amino-acid formula (AAF) and extensively hydrolyzed formula (eHF) based treatment of CMPA by using data available from Turkey and otherwise from literature. Materials and Methods A theoretical model was developed to evaluate AAF and eHF for CMPA treatment in terms of the number of children tolerating formula or experiencing an allergic reaction or withdrawing formula due to taste or other palatability features and CMPA related direct medical costs from the payer perspective. Results We estimated that 13,000 children are diagnosed with CMPA in 1 year in Turkey. For the children receiving AAF, it is estimated that 83.7% tolerate AAF until the 24th month, and the total cost for the children tolerating AAF is estimated at 20.6 million€. The average cost per child tolerating AAF until the 24th month is estimated at 1895€. On the other hand, 48.7% are estimated to tolerate eHF until the 24th month, and the total cost for the children tolerating eHF is estimated at 12.3 million€ and the average cost per child tolerating eHF until the 24th month is estimated at 1940€. Conclusion The analysis revealed that the management of CMPA is associated with the economic burden on the healthcare system in Turkey. Treatment of CMPA with AAF seems to provide better clinical outcomes (high tolerability and less withdrawal due to taste or an allergic reaction) and to be an option with economic benefits when Turkey-specific conditions are considered.
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Affiliation(s)
| | - Feza Kirbiyik
- Nutricia Advanced Medical Nutrition, Istanbul, Turkey
| | - Elif Aribal
- Nutricia Advanced Medical Nutrition, Istanbul, Turkey
| | - Anil Aksit
- Nutricia Advanced Medical Nutrition, Istanbul, Turkey
| | - Derya Ufuk Altintas
- Cukurova University Medical School, Allergy and Immunology Department, Adana, Turkey
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13
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Significant predictive factors of the severity and outcomes of the first attack of acute angioedema in children. BMC Pediatr 2019; 19:423. [PMID: 31707983 PMCID: PMC6844047 DOI: 10.1186/s12887-019-1809-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 10/28/2019] [Indexed: 11/24/2022] Open
Abstract
Background The initial episode of angioedema in children can be potential life-threatening due to the lack of prompt identification and treatment. We aimed to analyze the factors predicting the severity and outcomes of the first attack of acute angioedema in children. Methods This was a retrospective study with 406 children (< 18 years) who presented in the emergency department (ED) with an initial episode of acute angioedema and who had subsequent follow-up visits in the out-patient department from January 2008 to December 2014. The severity of the acute angioedema was categorized as severe (requiring hospital admission), moderate (requiring a stay in the short-term pediatric observation unit [POU]), or mild (discharged directly from the ED). The associations among the disease severity, patient demographics and clinical presentation were analyzed. Result In total, 109 (26.8%) children had severe angioedema, and the majority of those children were male (65.1%). Most of the children were of preschool age (56.4%), and only 6.4% were adolescents. The co-occurrence of pyrexia or urticaria, etiologies of the angioedema related to medications or infections, the presence of respiratory symptoms, and a history of allergies (asthma, allergic rhinitis) were predictors of severe angioedema (all p < 0.05). Finally, the duration of angioedema was significantly shorter in children who had received short-term POU treatment (2.1 ± 1.1 days) than in those who discharged from ED directly (2.3 ± 1.4 days) and admitted to the hospital (3.5 ± 2.0 days) (p < 0.001). Conclusion The co-occurrence of pyrexia or urticaria, etiologies related to medications or infections, the presence of respiratory symptoms, and a history of allergies were predictors of severe angioedema. More importantly, short-term POU observation and prompt treatment might be benefit for patients who did not require hospital admission.
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