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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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Calle CG, Díaz‐Vásquez C, Córdova‐Calderón W, Gómez de la Torre J, Matos‐Benavides E, Toribio‐Dionicio C. Clinical characteristics, laboratory findings, and tolerance acquisition in infants with cow's milk protein allergy in a private center in Lima, Peru for the period 2021-2022. Immun Inflamm Dis 2024; 12:e1246. [PMID: 38668747 PMCID: PMC11048966 DOI: 10.1002/iid3.1246] [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: 10/04/2023] [Revised: 03/11/2024] [Accepted: 03/31/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Cow's milk protein allergy (CMPA) remains relatively understudied in Latin America. METHODS In this observational study, we enrolled 64 patients with a median age of 3 months, of whom 60% were male. Patients included had a history of IgE-mediated reactions with IgE sensitization or non-IgE-mediated reactions or symptoms following exposure to cow's milk. They underwent skin prick test, ImmunoCAP, fecal calprotectin (FC), and fecal eosinophil-derived neurotoxin (EDN), in addition to double-blinded placebo-controlled oral food challenges (DBPCFC), with clinical evolution and tolerance acquisition observed over 1 year. RESULTS Malnutrition was present in 78.1% of patients, and 87.5% had a family history of atopy, with 51.6% receiving exclusive breastfeeding. Gastrointestinal manifestations were prevalent in 90.6% of patients, followed by dermatological manifestations (10.9%), with only 2 experiencing anaphylaxis. IgE-mediated CMPA was observed in only six patients. In those with non-IgE-mediated CMPA, FC had a median of 284 mg/dL (IQR: 138.5-415.5), while EDN had a median of 508.5 mg/dL (IQR: 160.25-868). One year after diagnosis, median FC significantly decreased (p < 0.0001), and malnutrition prevalence reduced to 17.1%. Moreover, 81% of patients acquired tolerance following DBPCFC, with 52% utilizing nutritional replacement formulas at diagnosis. Notably, 94% of those extensively hydrolyzed casein-based formulas achieved tolerance (p = 0.08). CONCLUSION Our findings provide a foundational framework for future investigations into CMPA diagnosis, tolerance acquisition, and the utilization of hypoallergenic formulas tailored to the unique characteristics of our region.
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Affiliation(s)
- César Galván Calle
- Asthma Allergy and ImmunologyInstituto Nacional de Salud del Niño – BreñaBreñaLimaPeru
- Instituto latinoamericano de AlergiasAsma e Inmunologia (ILAAI)LinceLimaPeru
- Emedic SaludSan IsidroLimaPeru
| | - Cecilia Díaz‐Vásquez
- Pediatrics UnitInstituto Nacional de Salud del Niño – San BorjaSan BorjaLimaPeru
| | - Wilmer Córdova‐Calderón
- Asthma Allergy and ImmunologyInstituto Nacional de Salud del Niño – BreñaBreñaLimaPeru
- Instituto latinoamericano de AlergiasAsma e Inmunologia (ILAAI)LinceLimaPeru
| | | | - Edgar Matos‐Benavides
- Asthma Allergy and ImmunologyInstituto Nacional de Salud del Niño – BreñaBreñaLimaPeru
- Instituto latinoamericano de AlergiasAsma e Inmunologia (ILAAI)LinceLimaPeru
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Salvatore S, Folegatti A, Ferrigno C, Pensabene L, Agosti M, D'Auria E. To Diet or Not to Diet This Is the Question in Food-Protein-Induced Allergic Proctocolitis (FPIAP)-A Comprehensive Review of Current Recommendations. Nutrients 2024; 16:589. [PMID: 38474718 DOI: 10.3390/nu16050589] [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: 01/15/2024] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Food-protein-induced allergic proctocolitis (FPIAP) is an increasingly reported transient and benign form of colitis that occurs commonly in the first weeks of life in healthy breastfed or formula-fed infants. Distal colon mucosal inflammation is caused by a non-IgE immune reaction to food allergens, more commonly to cow's milk protein. Rectal bleeding possibly associated with mucus and loose stools is the clinical hallmark of FPIAP. To date, no specific biomarker is available, and investigations are reserved for severe cases. Disappearance of blood in the stool may occur within days or weeks from starting the maternal or infant elimination diet, and tolerance to the food allergen is typically acquired before one year of life in most patients. In some infants, no relapse of bleeding occurs when the presumed offending food is reassumed after a few weeks of the elimination diet. Many guidelines and expert consensus on cow's milk allergy have recently been published. However, the role of diet is still debated, and recommendations on the appropriateness and duration of allergen elimination in FPIAP are heterogeneous. This review summarizes and compares the different proposed nutritional management of infants suffering from FPIAP, highlighting the pros and cons according to the most recent literature data.
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Affiliation(s)
- Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, 21100 Varese, Italy
| | - Alice Folegatti
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, 21100 Varese, Italy
| | - Cristina Ferrigno
- Department of Pediatrics, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Licia Pensabene
- Pediatric Unit, Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy
| | - Massimo Agosti
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, 21100 Varese, Italy
| | - Enza D'Auria
- Department of Pediatrics, Buzzi Children's Hospital, 20154 Milan, Italy
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McWilliam V, Netting MJ, Volders E, Palmer DJ. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - X - Breastfeeding a baby with cow's milk allergy. World Allergy Organ J 2023; 16:100830. [PMID: 38020284 PMCID: PMC10656250 DOI: 10.1016/j.waojou.2023.100830] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Cow's milk allergy is rare in exclusively breastfed infants. To support the continuation of breastfeeding an infant after diagnosis with a cow's milk allergy, it is critical to examine the evidence for and against any form of cow's milk elimination diet for lactating mothers. In this narrative review, we highlight the lack of high-quality evidence, hence subsequent controversy, regarding whether the minuscule quantities of cow's milk proteins detectable in human milk cause infant cow's milk allergy symptoms. Current clinical practice recommendations advise a 2-4 week trial of maternal cow's milk dietary elimination for: a) IgE-mediated cow's milk allergy only if the infant is symptomatic on breastfeeding alone; b) non-IgE-mediated associated symptoms only if the history and examination strongly suggest cow's milk allergy; and c) infants with moderate to severe eczema/atopic dermatitis, unresponsive to topical steroids and sensitized to cow's milk protein. There should be a clear plan for home reintroduction of cow's milk into the maternal diet for a period of 1 week to determine that the cow's milk elimination is responsible for resolution of symptoms, and then subsequent reoccurrence of infant symptoms upon maternal cow's milk reintroduction. The evidence base to support the use of maternal cow's milk avoidance for the treatment of a breastfed infant with cow's milk allergy is of limited strength due to a lack of high-quality, adequately powered, randomised controlled trials. It is important to consider the consequences of maternal cow's milk avoidance on reducing immune enhancing factors in breast milk, as well as the potential nutritional and quality of life impacts on the mother. Referral to a dietitian is advised for dietary education, along with calcium and vitamin D supplementation according to local recommendations, and a maternal substitute milk should be advised. However, for most breastfed infants with cow's milk allergy maternal cow's milk dietary elimination will not be required, and active support of the mother to continue breastfeeding is essential.
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Affiliation(s)
- Vicki McWilliam
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Merryn J. Netting
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Nutrition Department, Women's and Children's Health Network, North Adelaide, SA, Australia
| | - Evelyn Volders
- Nutrition, Dietetics & Food, Monash University, Clayton, Vic, Australia
| | - Debra J. Palmer
- Telethon Kids Institute, University of Western Australia, Nedlands, WA, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
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Soria R, Del Compare M, Sallaberry M, Martín G, Aprigliano G, Hermida V, Carosella M, Gruenberg M, Monsell S, Micone P, Maciero E, Giglio N. Efficacy of an extensively hydrolyzed formula with the addition of synbiotics in infants with cow's milk protein allergy: a real-world evidence study. FRONTIERS IN ALLERGY 2023; 4:1265083. [PMID: 37876766 PMCID: PMC10591099 DOI: 10.3389/falgy.2023.1265083] [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: 07/21/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Cow's milk protein allergy (CMPA) is the most frequent food allergy in early childhood. For those infants requiring breastmilk substitutes, formulas with extensively hydrolyzed proteins (EHF), should be the treatment of choice. As there are limited data showing the progression of initial symptoms in infants newly diagnosed with CMPA who are treated with EHF with added synbiotics, the main objective of this study was to evaluate the resolution of symptoms in said infants after 4 weeks of treatment. As a secondary objective this study aimed to assess the impact of the treatment on the family's quality of life. Materials and Methods observational, longitudinal, prospective, and multicentric real-world evidence study. The intervention phase (EHF with synbiotics) lasted 28 days and was completed by 65 patients. Treating physicians registered child´s anthropometry, Infant Gastrointestinal Symptoms Questionnaire (IGSQ-13) and CoMiSS (Cow´s Milk Allergy Symptoms Score) both at baseline and after 28 days of treatment. During treatment, caregivers reported child´s regurgitation and stools, PO-SCORAD (Patient Oriented Scoring of Atopic Dermatitis) and FAQL-PB (Family Quality of Life-Parental Burden). Data were collected using Google Forms and analyzed through the STATA program. Results 95.4% of the patients showed an improvement or disappearance of the overall initial symptoms after 4 weeks of treatment. Gastrointestinal symptoms improved or disappeared in 92% of patients (p < 0.05) while dermatological symptoms improved or disappeared in 87.5% of patients (p < 0.05). The median CoMiSS at baseline was 9, with 21 patients exceeding the cut-off point of 12. After 4 weeks of treatment, the median dropped to 3, and no patient exceeded the 12-cut-off point (p = 0.000). At baseline, patients had a PO-SCORAD of 11.5 (interquartile range 1-23) that went to 1.0 (interquartile range 1-6) at day 28 (p = 0.000). The treatment diminished stool frequency (p < 0.05), improved stool consistency (p = 0.004) and decreased the frequency of regurgitation in infants with CMPA (p = 0.01). The percentage of patients who no longer had any episode of regurgitation increased from 11% to 31% on day 28 (p = 0.003). At baseline, 13% of patients cried more than 3 h per day, while at day 28 that percentage dropped to 3% (p = 0.03). An improvement in the infants' sleep pattern was also appreciated with the treatment. At study onset, 56% of the families reported feeling very overwhelmed, a percentage that dropped to 17% after 28 days of treatment (p < 0.05). The small percentage of families who did not feel overwhelmed at study onset (17%), grew to 43% on day 28 (p < 0.05). Conclusions The use of an EHF with synbiotics for the management of infants diagnosed with or suspected to have CMPA suggested a good safety profile, an adequate infant growth, and improvement of overall, gastrointestinal, and dermatological symptoms. It also suggested a lower daily frequency of regurgitations and stools, and an improvement in stool consistency, sleeping pattern, and quality of life of the infant and his family.
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Affiliation(s)
- Ramiro Soria
- Sanatorio Infantil San Lucas, San Miguel de Tucumán, Tucumán, Argentina
| | - Mónica Del Compare
- Consultorios Externos Sanatorio Mater Dei, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Graciela Martín
- Clínica del Niño y Consultorios de Especialistas, Corrientes, Argentina
| | - Gustavo Aprigliano
- Consultorio Pediátrico Urquiza, Ciudad Autónoma de Buenos Aires, Argentina
| | - Verónica Hermida
- Consultorios Neuropediatría Barracas, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mabel Carosella
- Grupo Pediátrico BelgranoR, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Silvana Monsell
- Consultorio Privado, Ciudad Autónoma de Buenos Aires, Argentina
| | - Paula Micone
- Servicio de Tocoginecología, Hospital Durand, Ciudad Autónoma de Buenos Aires, Argentina
| | - Eugenia Maciero
- Grupo Pediátrico BelgranoR, Ciudad Autónoma de Buenos Aires, Argentina
| | - Norberto Giglio
- Grupo Pediátrico BelgranoR, Ciudad Autónoma de Buenos Aires, Argentina
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AL-Iede M, Sarhan L, Alshrouf MA, Said Y. Perspectives on Non-IgE-Mediated Gastrointestinal Food Allergy in Pediatrics: A Review of Current Evidence and Guidelines. J Asthma Allergy 2023; 16:279-291. [PMID: 36942164 PMCID: PMC10024490 DOI: 10.2147/jaa.s284825] [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: 12/23/2022] [Accepted: 02/17/2023] [Indexed: 03/15/2023] Open
Abstract
Food allergy is an immune-mediated disease that can result in considerable morbidity and even mortality, with a significant negative impact on patients' quality of life. It is characterized by allergic symptoms that can occur shortly after a relevant food allergen ingestion, or can be delayed or chronic, which make it more difficult for diagnosis. The symptoms of this disease can range from mild to severe, and rarely can cause anaphylaxis, a life-threatening allergic reaction. The prevalence of non-immunoglobulin E (IgE)-mediated food allergy is poorly established outside of cow's milk allergy, with an adjusted incidence ranging between 0.13% and 0.72%. Several disorders are classified as non-immunoglobulin E (IgE)-mediated food allergies that predominantly affect the gastrointestinal tract including food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), food protein-induced allergic enteropathy (FPE), and food protein-induced dysmotility disorders (GORD and constipation). Eosinophilic esophagitis (EoE) is listed in this group, even though it considered by some authorities to be mixed reaction with both IgE and cell-mediated immune response to be involved in the reaction. The most common types of non-IgE-mediated food allergy are food protein-induced enterocolitis syndrome (FPIES) and food protein-induced allergic proctocolitis (FPIAP). These disorders typically present in infancy and are often triggered by cow's milk protein. Patients with FPIES present with profuse emesis and dehydration, while FPIAP patients present with hematochezia in otherwise healthy infants. Since there are no specific confirmatory non-invasive diagnostic laboratory tests, the diagnosis is usually made clinically when typical symptoms improve upon the removal of the culprit food. Food reintroduction should be attempted, when possible, with documentation of symptoms of relapse to confirm the diagnosis. The management includes dietary avoidance, supportive treatment in the case of accidental exposure, and nutritional counseling. This review focuses on the clinical manifestations, epidemiology, management, and recent guidelines of the most common non-IgE-mediated food hypersensitivity disorders (FPIES, FPIAP, and FPE).
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Affiliation(s)
- Montaha AL-Iede
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Jordan University Hospital, Amman, Jordan
- Correspondence: Montaha AL-Iede, Division of Pediatric Pulmonology and Sleep Medicine, The University of Jordan, Queen Rania Street, Amman, 11972, Jordan, Tel + 962 65355000, Email ;
| | - Lena Sarhan
- Department of Pediatrics, Jordan University Hospital, The University of Jordan, Amman, 11942, Jordan
| | - Mohammad A Alshrouf
- Department of Pediatrics, Jordan University Hospital, The University of Jordan, Amman, 11942, Jordan
| | - Yazan Said
- Division of Allergy, Immunology, and pulmonology, Department of Pediatrics, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Hernández‐Almeida P, Vásconez‐Muñoz F, Vásconez‐Montalvo A, Sempértegui‐Moscoso R, Contreras G, Carrión‐Jaramillo E. Food protein‐induced enterocolitis syndrome with pneumatosis intestinalis in an exclusively breastfed infant: A case report and literature review. Clin Case Rep 2022; 10:e6520. [DOI: 10.1002/ccr3.6520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 09/25/2022] [Accepted: 10/09/2022] [Indexed: 11/25/2022] Open
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Toca MC, Morais MB, Vázquez-Frias R, Becker-Cuevas DJ, Boggio-Marzet CG, Delgado-Carbajal L, Higuera-Carrillo MM, Ladino L, Marchisone S, Messere GC, Ortiz GJ, Ortiz-Paranza LR, Ortiz-Piedrahita C, Riveros-López JP, Sosa PC, Villalobos-Palencia NC. Consensus on the diagnosis and treatment of cow's milk protein allergy of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:235-250. [PMID: 35623990 DOI: 10.1016/j.rgmxen.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein.
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Affiliation(s)
- M C Toca
- Sección Gastroenterología, Hepatología y Nutrición, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - M B Morais
- Escuela Paulista de Medicina, Universidad Federal de Sao Paulo, Sao Paulo, Brazil
| | - R Vázquez-Frias
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Salud Hospital Infantil de México Federico Gómez, Mexico City, Mexico.
| | - D J Becker-Cuevas
- Servicio de Pediatría, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - C G Boggio-Marzet
- Gastroenterología y Nutrición Pediátrica, División Pediatría, Departamento Materno Infanto Juvenil, Hospital Gral. de Agudos «Dr. I. Pirovano», Ciudad Autónoma de Buenos Aires, Argentina
| | - L Delgado-Carbajal
- Servicio de Gastroenterología, Hepatología y Nutrición Pediátrica, Unidad de Endoscopia Digestiva Pediátrica, Hospital Universitario «Centro Hospitalario Pereira Rossell», Montevideo, Uruguay
| | | | - L Ladino
- Instituto de Investigación en Nutrición, Genética y Metabolismo IINGM, Facultad de Medicina, Universidad El Bosque, Bogotá, Colombia
| | - S Marchisone
- Servicio de Gastroenterología, Hospital Infantil de Córdoba, Córboba, Argentina
| | - G C Messere
- Sección Gastroenterología, Hepatología y Nutrición, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - G J Ortiz
- Sección de Gastroenterología, Hepatología y Nutrición Infantil, Servicio de Pediatría, Hospital Nacional Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | - L R Ortiz-Paranza
- Hospital General Pediátrico «Niños de Acosta Ñu», Ministerio de Salud Pública y Bienestar Social, San Lorenzo, Paraguay
| | - C Ortiz-Piedrahita
- Departamento de Pediatría, Servicio de Gastroenterología Infantil, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - J P Riveros-López
- Unidad de Gastroenterología Pediátrica Juan Pablo Riveros SAS, Bogotá, Colombia
| | - P C Sosa
- Sección Gastroenterología, Hepatología y Nutrición Infantil, Servicio de Pediatría, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
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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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World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines update – IV – A quality appraisal with the AGREE II instrument. World Allergy Organ J 2022; 15:100613. [PMID: 36091188 PMCID: PMC9419447 DOI: 10.1016/j.waojou.2021.100613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/20/2021] [Accepted: 11/05/2021] [Indexed: 01/02/2023] Open
Abstract
Background Since the publication of The World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines in 2010, a number of other guidelines, expert opinions, and position papers relating to the management of cow's milk allergy (CMA) have been published. We aimed to systematically review the quality of the guidelines on CMA diagnosis and management in children and/or adults published between 2010 and 2020. Methods The MEDLINE, EMBASE, ISI Web of Science, World Health Organization Global Index Medicus, and Turning Research into Practice databases as well as website guideline repositories were searched from January 2010 until May 2020. Any clinical practice recommendations and/or guidelines focusing on the diagnosis and management of CMA in children and/or adults developed or endorsed by professional scientific societies or organizations were included. The guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool, a 23-item tool organized within 6 domains and 2 global rating items. Results We included 12 guidelines; 8 were developed by national and 4 by international organizations. The quality scores for each domain varied: of all domains, the clarity of presentation domain had the highest median score (92%; Q1-Q3 81–100%), whereas rigor of development had the lowest median score (30%; Q1-Q3 15–67%). The median scores (Q1-Q3) for individual domains were as follows: scope and purpose 82% (70–99%), stakeholder involvement 63% (21–79%), rigor of development 30% (15–67%), clarity of presentation 92% (81–100%), applicability 68% (57–75%), and editorial independence 75% (69–100%). The median overall score was 70% (58–89%). Only 1 guideline (from the National Institute for Health and Care Excellence [NICE]) achieved top ratings (100%) in five domains and the overall score. Three guidelines (from the NICE, the British Society for Allergy & Clinical Immunology [BSACI] and WAO) achieved the highest ratings (100%) in at least 3 domains and the overall score. Conclusion The majority of identified guidelines were of good or very good quality. However, the weakest point was the rigor of development domain, mostly due to unclear description of strengths and limitations of the body of evidence and the procedure for updating the guidelines.
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11
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García Sánchez P, Santos Simarro G, Sampredro Martín M, Valladares Salado L, Escolano Taravillo L. A Cyanotic Infant: Infrequent Presentation of Cow’s Milk Protein Allergy. Cureus 2022; 14:e21678. [PMID: 35242464 PMCID: PMC8884543 DOI: 10.7759/cureus.21678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 11/16/2022] Open
Abstract
We report the case of a three-month-old boy who presented with poor weight gain, loose stools, and poor oral intake for three weeks. Physical examination revealed a pale infant with abdominal distension and cyanosis. Oxygen saturation was normal, but the laboratory showed important methemoglobinemia. The diagnosis of FPIES (food protein-induced enterocolitis syndrome) in the context of cow’s milk protein allergy (CMPA) was suspected. Although CMPA is a common condition encountered in small children, chronic forms of FPIES can be difficult to diagnose. Maintaining clinical suspicion about the potential association between methemoglobinemia and gastrointestinal symptoms can lead to prompt recognition and intervention.
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12
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World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines update – I – Plan and definitions. World Allergy Organ J 2022; 15:100609. [PMID: 35145603 PMCID: PMC8818560 DOI: 10.1016/j.waojou.2021.100609] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/08/2021] [Accepted: 11/04/2021] [Indexed: 12/12/2022] Open
Abstract
Since the World Allergy Organization (WAO) Diagnosis and Rationale against Cow's Milk Allergy (DRACMA) Guidelines were published 10 years ago, new evidence has accumulated about the diagnosis, therapy, and specific immunotherapy for cow's milk allergy (CMA). For this reason, WAO has felt the need to update the guidelines. We introduce here this update. The new DRACMA guidelines aim to comprehensively address the guidance on diagnosis and therapy of both IgE non-IgE-mediated forms of cow's milk allergy in children and adults. They will be divided into 18 chapters, each of which will be dedicated to an aspect. The focus will be on the meta-analyzes and recommendations that will be expressed for the 3 most relevant clinical aspects: (a) the diagnostic identification of the condition; (b) the choice of the replacement formula in case of CMA in infancy when the mother is not able to breastfeed, and (c) the use of specific immunotherapy for cow's milk protein allergy.
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13
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Vandenplas Y, Brough HA, Fiocchi A, Miqdady M, Munasir Z, Salvatore S, Thapar N, Venter C, Vieira MC, Meyer R. Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy. J Asthma Allergy 2021; 14:1243-1256. [PMID: 34712052 PMCID: PMC8548055 DOI: 10.2147/jaa.s276992] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/08/2021] [Indexed: 12/13/2022] Open
Abstract
Abstract Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them. Conclusion A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Helen A Brough
- Department Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.,Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, UK
| | - Alessandro Fiocchi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, Rome, Italy
| | - Mohamad Miqdady
- Department of Pediatrics, Sheikh Khalifa Medical City, College of Medicine & Health Sciences, Khalifa University, Khalifa, United Arab Emirates
| | - Zakiudin Munasir
- Department of Child Health, Ciptomangunkusumo Hospital-Medical Faculty Universitas Indonesia, Jakarta, Indonesia
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Carina Venter
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Mario C Vieira
- Center for Pediatric Gastroenterology -Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Rosan Meyer
- Department of Paediatrics, Imperial College, London, UK.,Department Nutrition and Dietetics, University of Winchester, Winchester, UK
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14
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Calatayud-Sáez FM, Calatayud B, Calatayud A. Effects of the Traditional Mediterranean Diet in Patients with Otitis Media with Effusion. Nutrients 2021; 13:2181. [PMID: 34202888 PMCID: PMC8308248 DOI: 10.3390/nu13072181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Otitis media with effusion (OME) is common in pediatric primary care consultations. Its etiology is multifactorial, although it has been proven that inflammation factors mediate and that immunity is in a phase of relative immaturity. The objective of this study was to assess the effects of the Traditional Mediterranean Diet (TMD) modulating inflammation and immunity in patients diagnosed with OME. MATERIALS AND METHODS A analysis as a single-group pre-test/post-test was conducted on 40 girls and 40 boys between 18 months and 5 years old. Tympanometry normalization was the main test to control the benefit of diet. Clinical and therapeutic variables were studied through evaluation questionnaires, a quality test of the diet, as well as various anthropometric parameters. RESULTS At the end of one year, tympanometry had normalized in 85% of patients. The remaining 15% had normal audiometry and/or associated symptoms had decreased. Likewise, episodes of recurrent colds decreased from 5.96 ± 1.41 to 2.55 ± 0.37; bacterial complications of 3.09 ± 0.75 to 0.61 ± 0.06 and persistent nasal obstruction of 1.92 ± 0.27 to 0.26 ± 0.05. The degree of satisfaction of the families with the program was very high. CONCLUSIONS The application of the Traditional Mediterranean Diet could have promising effects in the prevention and treatment of otitis media with effusion.
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15
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Graczykowska K, Kaczmarek J, Wilczyńska D, Łoś-Rycharska E, Krogulska A. The Consequence of Excessive Consumption of Cow's Milk: Protein-Losing Enteropathy with Anasarca in the Course of Iron Deficiency Anemia-Case Reports and a Literature Review. Nutrients 2021; 13:828. [PMID: 33802302 PMCID: PMC8000842 DOI: 10.3390/nu13030828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 01/18/2023] Open
Abstract
Cow's milk is a key component of a child's diet. While the consumption of even trace amounts can result in allergy to its proteins and/or hypolactasia, excessive cow's milk consumption can result in numerous health complications, including iron deficiency, due to the diet being improperly balanced. Although the incidence of iron deficiency has declined, it remains the most widespread nutritional deficiency globally and the most common cause of anemia. One rare consequence of anemia caused by iron deficiency is protein-losing enteropathy; however, the mechanisms of its development are unclear. The following manuscript, based on a literature review, presents two rare cases of children, a 16-month-old boy and a 2.5-year-old girl, who developed severe microcytic anemia, enteropathy with hypoalbuminemia, and anasarca as a result of excessive cow's milk consumption. It highlights the possible relationship between excessive consumption of cow's milk in children and severe iron deficiency anemia with accompanying hypoalbuminemia; it may also result in serious clinical conditions, even in children that do not demonstrate food hypersensitivity.
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Affiliation(s)
- Karolina Graczykowska
- SRC Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
| | - Joanna Kaczmarek
- SRC Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
| | - Dominika Wilczyńska
- Department of Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (D.W.); (E.Ł.-R.); (A.K.)
| | - Ewa Łoś-Rycharska
- Department of Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (D.W.); (E.Ł.-R.); (A.K.)
| | - Aneta Krogulska
- Department of Pediatrics, Allergology and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (D.W.); (E.Ł.-R.); (A.K.)
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16
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Piñeiro Pérez R, Álvez González F, Baquero-Artigao F, Cruz Cañete M, de la Flor i Bru J, Fernández Landaluce A, García Vera C, Hijano Bandera F, Pérez Cánovas C, Silva Rico JC, Alfayate Miguélez S, Ares Álvarez J, Berghezan Suárez A, Borrull Senra AM, Cabrera Roca G, Calvo Rey C, Carazo Gallego B, Cilleruelo Ortega MJ, Conejo Fernández A, López Ávila J, Lupiani Castellanos P, Martínez Campos L, Sotoca Fernández J. Actualización del documento de consenso sobre el diagnóstico y tratamiento de la faringoamigdalitis aguda. An Pediatr (Barc) 2020; 93:206.e1-206.e8. [DOI: 10.1016/j.anpedi.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 10/24/2022] Open
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17
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Diagnosis and treatment of acute tonsillopharyngitis. Consensus document update. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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18
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Kubo C, Kurimoto M, Tanaka M, Ochi H, Abe F, Okochi M. Peptide array-based inhibition ELISA for evaluating antigenicity in infant formulas. J Biosci Bioeng 2020; 130:374-381. [PMID: 32713812 DOI: 10.1016/j.jbiosc.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/02/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022]
Abstract
With increased awareness among consumers regarding food safety and security, food allergen control has become an indispensable requirement in the food industry. Although several methods for detecting allergens in food products are available, highly sensitive techniques are required. In this study, we developed a technique named as peptide array-based inhibition enzyme-linked immunosorbent assay (ELISA), Pep-iEIA, for evaluating antigenicity and detecting cow's milk antigen in infant formula products, using a peptide array consisting of a series of overlapping peptides found in allergenic milk proteins. Pep-iEIA was used to examine five cow's milk-based infant formulas with different degrees of hydrolyzation, and the assay offered both more sensitive detection and detailed analysis of remaining antigenic peptides in allergen compared to conventional ELISA. The antigenicity level of the allergenic peptides identified using Pep-iEIA was confirmed by surface plasmon resonance assay. We believe that Pep-iEIA will be highly useful for antigenicity evaluation of dairy products consumed by infants and patients with cow's milk allergy.
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Affiliation(s)
- Chisato Kubo
- Food Ingredients & Technology Institute, Morinaga Milk Industry Co., Ltd., 5-1-83 Higashihara, Zama, Kanagawa 252-8583, Japan
| | - Masaki Kurimoto
- Food Ingredients & Technology Institute, Morinaga Milk Industry Co., Ltd., 5-1-83 Higashihara, Zama, Kanagawa 252-8583, Japan
| | - Masayoshi Tanaka
- Department of Chemical Science and Engineering, Tokyo Institute of Technology, 2-12-1 O-okayama, Meguro-ku, Tokyo 152-8552, Japan
| | - Hiroshi Ochi
- Food Ingredients & Technology Institute, Morinaga Milk Industry Co., Ltd., 5-1-83 Higashihara, Zama, Kanagawa 252-8583, Japan
| | - Fumiaki Abe
- Food Ingredients & Technology Institute, Morinaga Milk Industry Co., Ltd., 5-1-83 Higashihara, Zama, Kanagawa 252-8583, Japan
| | - Mina Okochi
- Department of Chemical Science and Engineering, Tokyo Institute of Technology, 2-12-1 O-okayama, Meguro-ku, Tokyo 152-8552, Japan.
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19
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Pérez Ajami RI, Carrión Sari SK, Aliaga Mazas Y, Calvo JB, Guallar Abadía MI. Experience in food protein-induced enterocolitis syndrome in a paediatric allergy clinic. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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20
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Munblit D, Perkin MR, Palmer DJ, Allen KJ, Boyle RJ. Assessment of Evidence About Common Infant Symptoms and Cow's Milk Allergy. JAMA Pediatr 2020; 174:599-608. [PMID: 32282040 DOI: 10.1001/jamapediatrics.2020.0153] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Sales of specialized formula for managing cow's milk allergy (CMA) have increased, triggering concern that attribution of common infant symptoms, such as crying, vomiting, and rashes, to CMA may be leading to overdiagnosis, which could undermine breastfeeding. OBJECTIVE To understand whether CMA guideline recommendations might promote CMA overdiagnosis or undermine breastfeeding. EVIDENCE REVIEW We reviewed recommendations made in CMA guidelines and critically appraised 2 key recommendations. First, we reviewed relevant literature summarizing whether maternal or infant dietary exclusion of cow's milk is effective for managing common infant symptoms. Second, we reviewed published data on breastmilk composition and thresholds of reactivity in CMA to estimate the probability that cow's milk protein in human breastmilk can trigger symptoms in infants with CMA. We also documented the level of commercial involvement in CMA guidelines. FINDINGS We reviewed 9 CMA guidelines published from 2012 to 2019. Seven suggest considering CMA as a cause of common infant symptoms. Seven recommend strict maternal cow's milk exclusion for managing common symptoms in breastfed infants. We found CMA proven by food challenge affects approximately 1% of infants, while troublesome crying, vomiting, or rashes are each reported in 15% to 20% of infants. We found clinical trials do not provide consistent support for using maternal or infant cow's milk exclusion to manage common symptoms in infants without proven CMA. We estimated that for more than 99% infants with proven CMA, the breastmilk of a cow's milk-consuming woman contains insufficient milk allergen to trigger an allergic reaction. Three CMA guidelines were directly supported by formula manufacturers or marketing consultants, and 81% of all guideline authors reported a conflict of interest with formula manufacturers. CONCLUSIONS AND RELEVANCE Recommendations to manage common infant symptoms as CMA are not evidence based, especially in breastfed infants who are not directly consuming cow's milk. Such recommendations may cause harm by undermining confidence in breastfeeding.
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Affiliation(s)
- Daniel Munblit
- National Heart and Lung Institute, Imperial College London, London, England.,Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child Health, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Michael R Perkin
- Population Health Research Institute, St George's, University of London, Cranmer Terrace, London, England
| | - Debra J Palmer
- Telethon Kids Institute, The University of Western Australia, Western Australia, Australia
| | - Katie J Allen
- Murdoch Children's Research Institute, The University of Melbourne, Victoria, Australia
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, England.,Centre for Evidence-Based Dermatology, University of Nottingham, Nottingham, England
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21
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Pérez Ajami RI, Carrión Sari SK, Aliaga Mazas Y, Calvo JB, Guallar Abadía MI. [Experience in food protein-induced enterocolitis syndrome in a paediatric allergy clinic]. An Pediatr (Barc) 2020; 92:345-350. [PMID: 32127302 DOI: 10.1016/j.anpedi.2019.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/16/2019] [Accepted: 09/30/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Food Protein-Induced Enterocolitis Syndrome (FPIES) is a gastrointestinal syndrome due to a non-IgE mediated food hypersensitivity.. The most common triggers are cow's milk and soy. Fish is one of the most frequently reported causes in Spain. The objective of this study is to describe the clinical characteristics of patients diagnosed with (FPIES) in a Paediatric Allergy Clinic. MATERIAL AND METHODS A retrospective descriptive study was carried out by reviewing medical records of patients diagnosed with FPIES in the Paediatric Allergy Unit of the Miguel Servet Children's Hospital from the years 2007 to 2017. RESULTS A total of 135 patients were diagnosed during the study period, of whom 45% were male and 55% were female. The mean age at diagnosis was 11±1.5 months and the mean age of improvement was 2 years and 6 months±2.5 years (n=83). A personal history of atopy was observed in 31.9%. The main trigger foods were: white fish (41.4%), cow's milk (25.1%), and egg (15.5%). A conversion to IgE-mediated allergy was seen in 4.4% of patients. There was vomiting in 81.5% of the cases, with a mean of 1.75±1.1hours of latency, as well as diarrhoea in 41.5%, with a mean of 7.86±15.16hours of latency, and decline in 30.4% with a mean latency of 3.81±11.57hours. DISCUSSION In our series, the most frequent trigger of the FPIES was fish. It was manifested mainly by late vomiting and a tolerance was reached mostly at 2 years 6 months.
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22
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Guadamuro L, Diaz M, Jiménez S, Molinos-Norniella C, Pérez-Solis D, Rodríguez JM, Bousoño C, Gueimonde M, Margolles A, Delgado S, Díaz JJ. Fecal Changes Following Introduction of Milk in Infants With Outgrowing Non-IgE Cow's Milk Protein Allergy Are Influenced by Previous Consumption of the Probiotic LGG. Front Immunol 2019; 10:1819. [PMID: 31428100 PMCID: PMC6689952 DOI: 10.3389/fimmu.2019.01819] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/18/2019] [Indexed: 12/11/2022] Open
Abstract
Cow's milk protein allergy (CMPA) is the most common allergy in the first year of life. Non-IgE mediated CMPA is characterized by digestive symptoms and tolerance development before the age of three. Gut microbiota composition in early life has been associated with food allergy. The ingestion of different foods/nutrients may mark different shifts in the microbial colonization of the infant intestine as well as the consumption of probiotics. Aim: To analyze changes in microbiota composition and metabolic and cytokine profiles in fecal samples from infants with non-IgE mediated CMPA after successful milk challenges, tolerance acquisition, and increasing dairy introduction in their diet. Methods: Twelve children with CMPA, aged between 1 and 2 years old, were recruited for the study. Participants were initially consuming hypoallergenic hydrolyzed formulas (four of them supplemented with the probiotic Lactobacillus rhamnosus GG), before being exposed to a standardized oral challenge (SOC) with cow's milk. Fecal samples were collected before, 1 week, and 1 month after performing the SOC. Changes in gut microbiota were determined by high-throughput amplicon sequencing of the 16S rRNA gene. Levels of lactobacilli were also determined by quantitative PCR (qPCR). Microbial metabolites were analyzed by chromatographic methods and fecal cytokines related to the Th1/Th2 balance were determined by immunoassay. Results: Lactic acid bacteria significantly increased in infants who outgrew non-IgE CMPA, after the introduction of milk. Microbial metabolites derived from the fermentation of proteins, such as branched chain fatty acids, and p-cresol, diminished. After the SOC, some cytokines related to inflammation (TNF-α, IFN-γ) increased. Accompanying the introduction of an unrestricted diet, we found significant differences in fecal microbial composition, metabolites, and cytokines between infants who did not consume the probiotic L. rhamnosus GG and those that did. Conclusions: These findings indicate that the introduction of intact milk proteins is followed by modifications in the infant gut environment through changes in immune mediators, microbiota, and its metabolic end-products. Consumption of probiotics during CMPA may contribute to gut homeostasis by fine-tuning these profiles.
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Affiliation(s)
- Lucía Guadamuro
- Department of Microbiology and Biochemistry of Dairy Products, Instituto de Productos Lácteos de Asturias (IPLA)-Consejo Superior de Investigaciones Científicas (CSIC), Villaviciosa, Spain
| | - Maria Diaz
- Department of Microbiology and Biochemistry of Dairy Products, Instituto de Productos Lácteos de Asturias (IPLA)-Consejo Superior de Investigaciones Científicas (CSIC), Villaviciosa, Spain
| | - Santiago Jiménez
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Pediatric Gastroenterology, Hepatology and Nutrition Section, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | | | - David Pérez-Solis
- Pediatrics Service, Hospital Universitario San Agustín, Avilés, Spain
| | - Juan Miguel Rodríguez
- Department of Nutrition and Food Science, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Carlos Bousoño
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Pediatric Gastroenterology, Hepatology and Nutrition Section, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Miguel Gueimonde
- Department of Microbiology and Biochemistry of Dairy Products, Instituto de Productos Lácteos de Asturias (IPLA)-Consejo Superior de Investigaciones Científicas (CSIC), Villaviciosa, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Abelardo Margolles
- Department of Microbiology and Biochemistry of Dairy Products, Instituto de Productos Lácteos de Asturias (IPLA)-Consejo Superior de Investigaciones Científicas (CSIC), Villaviciosa, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Susana Delgado
- Department of Microbiology and Biochemistry of Dairy Products, Instituto de Productos Lácteos de Asturias (IPLA)-Consejo Superior de Investigaciones Científicas (CSIC), Villaviciosa, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Juan José Díaz
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Pediatric Gastroenterology, Hepatology and Nutrition Section, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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