Nutritional management of cow's milk allergy in children: An update

Exploring the gut microbiota landscape in cow milk protein allergy: Clinical insights and diagnostic implications in pediatric patients

Cow milk protein allergy (CMPA) is a significant health concern characterized by adverse immune reactions to cow milk proteins. Biomarkers for the accurate diagnosis and prognosis of CMPA are lacking. This study analyzed the clinical features of CMPA, and 16S RNA sequencing was used to investigate potential biomarkers through fecal microbiota profiling. Children with CMPA exhibit a range of clinical symptoms, including gastrointestinal (83% of patients), skin (53% of patients), and respiratory manifestations (26% of patients), highlighting the complexity of this condition. Laboratory analysis revealed significant differences in red cell distribution width and inflammatory markers between the CMPA and control groups, suggesting immune activation and inflammatory responses in CMPA. Microbial diversity analysis revealed higher specific diversity indices in the CMPA group compared with those in control group, with significant differences at the genus and species levels. Bacteroides were more abundant in the CMPA group, whereas Bifidobacterium, Ruminococcus, Faecalibacterium, and Parabacteroides were less abundant. The control group exhibited a balanced microbial profile, with a predominant presence of Bifidobacterium bifidum and Akkermansia muciniphila. The significant abundance of Bifidobacterium in the control group (23.19% vs. 9.89% in CMPA) was associated with improved growth metrics such as height and weight, suggesting its potential as a probiotic to prevent CMPA and enhance gut health. Correlation analysis linked specific microbial taxa such as Coprococcus and Bifidobacterium to clinical parameters such as family allergy history, weight, and height, providing insights into CMPA pathogenesis. Significant differences in bacterial abundance suggested diagnostic potential, with a panel of 6 bacteria achieving high predictive accuracy (area under curve = 0.8708). This study emphasizes the complex relationship between the gut microbiota and CMPA, offering valuable insights into disease mechanisms and diagnostic strategies.

Impact of metabolic syndrome factors on sperm DNA fragmentation in males from infertile couples: A systematic review and meta-analysis

PURPOSE

To investigate the impact of metabolic syndrome factors on sperm DNA fragmentation (sDF) in males from infertile couples.

METHODS

A systematic literature search was performed across ten databases for literature published from January 1, 2013 until September 13, 2023. The protocol has been registered on PROSPERO (CRD42023458359), and the literature search strategy is adhered to the PRISMA framework. Studies that evaluated sDF, as indicated by DNA fragmentation index (%DFI), in males from infertile couples in relation to metabolic syndrome factors were included. Meta-analysis, using random effects model and Bayesian framework network, was performed, and data were presented as Standardized Mean Differences (SMD) with corresponding 95 % Confidence Interval (CI).

RESULTS

Of the 2579 citations identified, eleven studies were included in this meta-analysis. The findings revealed that the %DFI was not associated with overall metabolic syndrome factors (p-tot = 0.235; SMD = 0.57 [95 %CI: -0.37, 1.52]), metabolic syndrome status (p-tot = 0.337; SMD = 0.08 [95 %CI: -0.08, 0.24), increased body mass index (p-tot = 0.237; SMD = 0.71 [95 %CI: -0.47, 1.89]), or glycaemic profile (p-tot = 0.93; SMD = 0.13 [95 %CI: -2.72, 2.98]). High levels of heterogeneity were observed (p < 0.01) in all subgroups, except for metabolic syndrome status.

CONCLUSION

The association between metabolic syndrome factors and sDF is conflicting. However, interpreting the association requires caution, as confounding factors, indicated by high heterogeneity, may conceal the outcome. Metabolic syndrome may influence other factors contributing to male infertility, highlighting the importance of promoting a healthy lifestyle.

Evolutive Study of Dietary Aspects and Intestinal Microbiota of Pediatric Cohort with Cow's Milk Protein Allergy

BACKGROUND

One of the most common food allergies in the pediatric population is allergy to cow's milk protein (CMPA). Treatment consists of avoiding cow's milk proteins in lactating mothers and/or using therapeutic formulas based on hydrolysates or vegetable formulas. In infants with CMPA at diagnosis, a different gut microbial profile has been found compared to healthy children, with a reduction in beneficial bacteria. The aim of this study was to evaluate changes in the gut microbiota profile and its metabolites, dietary patterns and anthropometric variables in a pediatric cohort with CMPA after six months on a restrictive diet compared to healthy controls.

METHODS

In total, 21 patients diagnosed with CMPA and a control group of 24 healthy infants participated in this study. The fecal microbiota of all participants were investigated by metataxonomic analysis of 16S rDNA amplicons, and fecal short-chain fatty acids were measured by gas chromatography. Epidemiological assessment and dietary questionnaires were carried out for both groups.

RESULTS

Regarding growth, no significant differences were found, but differences in dietary intake of some macro- and micronutrients were observed. Patients who were breastfed at six months had higher bifidobacteria and lipid intakes than patients fed with hydrolyzed formulas.

CONCLUSIONS

Although the growth of CMPA infants fed with therapeutic formula is similar to breastfed CMPA infants, there are differences in microbiota composition and macronutrient intake that underline the importance of continued breastfeeding in CMPA cases.

Elimination Diets in Lactating Mothers of Infants with Food Allergy

Breastfeeding is the most important nutrition source for infants. However, managing breastfed infants with signs and symptoms related to food allergy can be difficult. Many studies have shown the presence of different food allergens in breast milk, but the clinical role of these antigens in human milk is still much debated. Milk is the main suspect in exclusively breastfed infants with signs and symptoms attributable to food allergy, even if other foods may be responsible. This narrative review analyzes the recommendations provided by international guidelines to determine the diagnosis and management of IgE-mediated and non-IgE-mediated food allergies in exclusively breastfed infants. Dietary restrictions in lactating mothers of infants with suspected FA are usually not necessary. Only in the very few cases where significant allergy signs and symptoms occur in the infant during exclusive breastfeeding should the lactating mother follow an elimination diet for the suspected food for a short period.

Nutritional status and feeding difficulties in children up to 2 years of age with cow's milk allergy

BACKGROUND/OBJECTIVES

To assess the nutritional status and incidence of feeding difficulties in Polish children up to 2 years of age with cow's milk allergy (CMA) on cow's milk proteins-free diet.

METHODS

A cross-sectional, multi-center study included children aged 6 months to 2 years with confirmed or suspected (without oral food challenge) diagnosis of CMA on the elimination diet for at least 1 month. The primary outcomes were an assessment of proportion of children with impaired nutritional status (with the weight for length and body mass index (BMI) z-score > 1 and <-1), and feeding difficulties according to the Montreal Children's Hospital Feeding Scale. Children with confirmed and suspected CMA were assessed separately.

RESULTS

A 144 children with confirmed CMA and 88 with suspected CMA were included (57 and 78% with multiple food allergies, respectively). Among children with confirmed CMA, one-third (35.5%) of participants had any nutritional status impairment regardless of definition. Among those, most of children had mild malnutrition (10.4 vs. 9%) and possible risk of overweight (11.1 vs. 9.7%; following respectively BMI for age and weight for length z-scores). Only 16.0% of children had feeding difficulties. Feeding difficulties was identified to be a risk factor for moderate malnutrition compared to children without feeding difficulties (odds ratio 10, 95% confidence interval: 4-27).

CONCLUSIONS

Mild malnutrition and possible risk of overweight are concern in children up to 2 years of age on cow's milk proteins-free diet. Feeding difficulties are less common, however, may affect the nutritional status.

A retrospective comparison of IgE-mediated cow's milk protein allergy management strategies in pediatric cohorts

BACKGROUND

Complete avoidance of milk is the usual management for IgE-mediated cow's milk protein allergy (CMPA). A baked milk ladder is a method of dietary advancement therapy in IgE-mediated CMPA in Ireland, while in Spain, avoidance of milk awaiting natural tolerance acquisition through an oral food challenge (OFC) is employed. The aim of this study was to evaluate the use of dietary advancement therapy using a milk ladder compared with complete avoidance of milk for managing IgE-mediated CMPA.

METHODS

This is a retrospective chart review of 371 pediatric patients from the population who have been treated for IgE-mediated CMPA between 2011 and 2020, with the milk ladder (Ireland) or complete avoidance followed by an OFC (Spain). The main outcome was the introduction of cow's milk.

RESULTS

Milk ladder patients were 3.67 times more likely to succeed in comparison with milk avoidance (p < .001). Anaphylaxis during the treatment period occurred in 34 patients in the milk avoidance groups, while three patients in the milk ladder group experienced anaphylaxis due to accidental exposure to milk (p < .001). Failure to complete treatment was associated with a higher skin prick test in the milk avoidance group and a raised specific IgE in the milk ladder group.

CONCLUSION

This is the first study that compares outcomes of dietary advancement therapy to complete avoidance for CMPA management, demonstrating that cow's milk can be successfully and safely reintroduced using dietary advancement therapy using a milk ladder.

Comprehensive Care and Education Can Improve Nutritional and Growth Outcomes in Children with Persistent Cow's Milk, Egg, or Peanut Allergies: A Five-Year Follow-Up Study of Nutritional Status

BACKGROUND

Data suggest that food allergies greatly impact a child's health and growth due to inadequate nutrient intake. Our study aimed to establish the long-term outcome of children with food allergies compared to a control group.

METHODS

This study was a retrospective cohort study with longitudinal follow-up with a mean period of 4.85 years from the diagnosis to the last study visit. The patients' nutritional intake was assessed using a three-day food diary and analysed by a dietitian. Patients (61 boys and 33 girls, mean age 6.9 years) had a single food allergy including 21 patients with cow's milk, 34 with egg, and 39 with peanut allergies. The control group included 36 children (19 boys and 17 girls, mean age 8.03 years). Blood analysis was performed on all participants.

RESULTS

Data from our study showed that patients with cow's milk, egg or peanut allergies had normal growth and achieved catch-up growth from the diagnosis until the last study visit. In the cow's milk allergy group, the allergy was shown to affect calcium intake (p < 0.05), while egg and peanut allergies did not impact the dietary intake of nutrients. None of the investigated food allergies affected blood results (p < 0.05).

CONCLUSIONS

In the present study, we showed that single food allergies do not compromise growth in children if they are provided with appropriate support and that the affected children reach catch-up growth from the diagnosis.

The step-down approach in children with cow's milk allergy: Results of a randomized controlled trial

BACKGROUND

The Step-Down Approach for Cow's Milk Allergy (SDACMA) trial evaluated the tolerability and the rate of immune tolerance acquisition in CMA children starting dietary treatment with amino acid-based formula (AAF) and then switching to EHCF containing the probiotic Lacticaseibacillus  rhamnosus GG (EHCF + LGG).

METHODS

Randomized controlled trial involving IgE-mediated CMA children receiving AAF from at least 4 weeks. EHCF + LGG tolerance was evaluated by the results of double-blind placebo-controlled food challenge (DBPCFC). Subjects tolerating EHCF + LGG were randomly allocated to remain on AAF, or to switch to EHCF + LGG. Immune tolerance acquisition to cow's milk proteins was evaluated with DBPCFC after 12 months of treatment. Allergy screening tests and body growth were also monitored.

RESULTS

Sixty IgE-mediated CMA children were enrolled. The proportion of children treated with AAF who resulted tolerant to the first exposure of EHCF + LGG was 0.98 (exact 95% CI 0.91-0.99). The rate of the immune tolerance acquisition to cow milk proteins after 12 months treatment was higher in the EHCF + LGG (0.48, 95% exact CI 0.29-0.67, n/N = 14/29) than in the AAF group (0.03, 95% exact CI 0.001-0.17, n/N = 1/30). There was an absolute benefit increase (ABI) of tolerance rate equal to 0.45 (95% CI 0.23-0.63, Newcombe method 10) for EHCF + LGG versus AAF, corresponding to a NNT of 2 (2-4, Bender's method). A normal body growth pattern was observed in the two study groups.

CONCLUSION

In IgE-mediated CMA children the step-down from AAF to EHCF + LGG is well tolerated and could facilitate the immune tolerance acquisition.

The Effect of Food Allergen Exclusion on the Growth of Saudi Children

With a variety of symptoms that can impede children's development, food allergies are an important public health concern. With the help of information from the King Fahad Medical City Hospital in Riyadh, we looked at how restricting certain foods affected the growth of Saudi children who had food allergies. An anonymous self-administered questionnaire asking about the individuals' demographics and their restricted eating habits was completed by 72 children (48 boys and 24 girls) between the ages of 2 and 14. The sensitivity of six allergens (hen eggs, cow milk, fish, wheat, peanuts, and soybeans), anthropometric indices, specific Immunoglobulin E (IgE) levels, and sensitivity were examined. The Statistical Package for Social Science (SPSS), version 26, was used to analyze the data. Chi-square and t-tests were used to examine the relationships between various category variables. According to the findings, most of the mothers of the children were between the ages of 30 and 40 (80.6%), had a college degree (72.3%), were unemployed (59.7%), and had a monthly family income between 5000 and 15,000 SAR (69.4%). Both sexes had specific IgE antibodies for allergens in classes 2 and 3, with boys having noticeably (p ≤ 0.05) higher quantities than girls. While females were more sensitive to fish and peanuts, boys were more likely than girls to show specific IgE sensitivity to egg white, cow milk, wheat, and soybeans. Both sexes' allergy levels were considerably (p ≤ 0.01) higher in children aged 5.01 to 10 than in other age groups. In terms of classifications of thinness, overweightness, and obesity, boys were slenderer than girls, and a greater percentage of boys than girls were overweight or obese. The exclusion of hen eggs, cow milk, wheat, and peanuts from the diet had a significant and detrimental effect on body mass index (BMI) and height-for-age ratio among children with impaired growth, in contrast to the demographic factors, which had a significant and favorable effect on the growth of other children. In conclusion, restrictions on food allergens impairs growth in Saudi children, particularly boys' growth.

Molecular Mechanism and Clinical Effects of Probiotics in the Management of Cow's Milk Protein Allergy

Cow's milk protein allergy (CMPA) is the most common food allergy (FA) in infancy, affecting approximately 2% of children under 4 years of age. According to recent studies, the increasing prevalence of FAs can be associated with changes in composition and function of gut microbiota or "dysbiosis". Gut microbiota regulation, mediated by probiotics, may modulate the systemic inflammatory and immune responses, influencing the development of allergies, with possible clinical benefits. This narrative review collects the actual evidence of probiotics' efficacy in the management of pediatric CMPA, with a specific focus on the molecular mechanisms of action. Most studies included in this review have shown a beneficial effect of probiotics in CMPA patients, especially in terms of achieving tolerance and improving symptoms.

Evolution of nutritional status and associated factors among formula-fed infants with cow's milk protein allergy in a government program

BACKGROUND

Cow's milk protein allergy (CMPA) is a common allergy in infants and can affect proper growth and development. This study verified factors associated with the evolution of the nutritional status (NS) among infants with CMPA fed with hypoallergenic formulas (HF).

METHODS

This is a longitudinal study of infants (n = 1036) participating on a governmental program in Brazil. Researchers assessed Nutritional status before HF treatment (T1) and after HF treatment (T2). The causality of exposure variables on the evolution of NS was verified by Multinomial Logistic Regression (MLR).

RESULTS

We observed an increase in anthropometric indexes analyzed with statistically significant results (p < 0.01). The weight/age and height/age scores showed a significant reduction in infants with nutritional deficit. The Body Mass Index (BMI) showed a decrease in the number of infants with nutritional deficit (< -2 z-score). On the other hand, there was an increase in those classified as at risk of overweight, overweight and obese. MLR showed that those who remained < 12 months in the program had a lower odds ratio (95% CI = 0.355-0.906; p = 0.018) to have inadequate NS with increasing BMI. Preterm infants were 4 times more likely (CI 95% = 1.520-10.694; p = 0.005) to have their BMI decreased and those who received nutritional counseling had a lower odds ratio (CI 95% = 0.411-0.953; p = 0.029) to maintain adequate NS.

CONCLUSION

The program has a significant impact on the NS of infants with CMPA. The constant management and implementation of differentiated criteria according to the evolution of NS for the supply of HF is fundamental in the continuity of this public policy.

Association of food allergy in children with vitamin D insufficiency: a systematic review and meta-analysis

Current literature regarding the association of vitamin D insufficiency and food allergy is contradicting. The purpose of our study was to investigate this association. This is a systematic review and meta-analysis according to the PRISMA statement. PubMeD and Scopus databases were systematically searched for case-control studies investigating the association between pediatric food allergy and vitamin D insufficiency. Our search yielded 806 studies. Ten final studies were considered eligible for qualitative and quantitative analysis. Children with vitamin D insufficiency were found to have 68% more probability to present a food allergy episode (adjusted pooled OR: 1.68, 95% CI [1.25-2.27], p-value: 0.001). In their second year of life they were 4 times more likely to present a food allergy episode (adjusted pooled OR: 4.06, 95% CI [1.93-8.56], p-value: < 0.001), and 56% more probable to develop food sensitization (OR: 1.56, 95% CI [1.15-2.11], p-value: < 0.004). Children in Australia with vitamin D insufficiency were almost 4 times more likely to develop egg sensitization (adjusted OR: 3.79, 95% CI [1.19-12.08], p-value: 0.024). Children with vitamin D insufficiency were almost twice as likely to have peanut sensitization (OR: 1.96, 95% CI [1.08-3.57], p-value: 0.028).  Conclusion: Decreased maternal vitamin D levels and infant vitamin D insufficiency appear to increase the incidence of food allergies, particularly in the second year of life. To confirm this association, multicenter longitudinal studies are required. What is Known: • In newborns and young children, vitamin D deficiency and insufficiency are prevalent. • The exact role of vitamin D in atopic diseases remains controversial. What is New: • Decreased maternal vitamin D levels and infant vitamin D insufficiency appear to increase the incidence of food allergies. This association is more evident in the second year of life.

Management of IgE-mediated food allergy in the 21st century

The 21st century has seen the propulsion of research in the field of food allergy, which has driven real changes in the clinical approach. Allergen immunotherapy has been recommended for the active management of food allergy. Data have shown promising additional methods of treatment, including biologics. Efforts have been devoted to the risk stratification of food allergy and the standardization of the assessment of food-allergic severity. Alternative routes of administration of epinephrine are under investigation to minimize any mechanical issue and the fear of injections. Evidence-based guidelines have been published by the main international societies in the field of anaphylaxis and food allergy management and new updates are in preparation. In the coming years, treatment options that are currently in pre-clinical or early clinical evaluation will hopefully lead to safe and effective disease-modifying therapies for food allergy in clinical practice. The identification of reliable biomarkers and the standardization of definitions and measurement approaches, alongside a shared decision-making with patients and families, will be key for the development of personalized care and to help minimize the substantial burden of food allergy.

Hydrolyzed rice formula for dietary management of infants with cow's milk allergy

Background

Allergic diseases are increasing globally and are a significant public health challenge, especially in children. Cow's milk allergy (CMA) is one of the most common food allergies in early childhood. When CMA is diagnosed and exclusive breastfeeding is not possible, current guidelines recommend extensively hydrolyzed formulas (eHF) or amino acid-based formulas (AAF), depending on the diagnosis and severity of symptoms. Hydrolyzed rice formulas (HRF) are considered an alternative to eHF and AAF where available.

Objectives & methods

We aimed to understand how HRF are being used and their position in the management of CMA, and to generate consensus on indications for use. Two virtual roundtables of international healthcare experts in pediatric food allergy focused on HRF were convened in May and October 2021. Experts provided multiple perspectives due to different specialties, locations, healthcare settings, and availability of HRF. Following discussion of international CMA guidelines and HRF use, identification of challenges along the diagnosis and treatment pathway, and translation of guidelines into clinical practice, an expert consensus on the use of HRF for CMA was developed. This involved repeated voting followed by statement amendment to reach 100% agreement. This publication summarizes insights from these meetings.

Results

There was 100% agreement on all 8 statements: (1) While breastmilk is the best source of nutrition for infants with CMA, when breastfeeding is not possible, a hypoallergenic formula can be used; (2) Per definition, a HRF is cow's milk protein-free; (3) A minority of infants with immunoglobulin (Ig)E-mediated CMA react to eHF due to residual cow's milk protein; (4) More infants with non-IgE-mediated CMA than IgE-mediated CMA react to eHF likely due to residual cow's milk protein; (5) When a diagnostic elimination diet is indicated, HRF can be used; (6) A HRF can be recommended as a first-line option for CMA, where available, as outlined in the Diagnosis and Rationale for Action against Cow's Milk Allergy guidelines; (7) HRFs have proven hypoallergenicity and are suitable for the dietary management of CMA; (8) HRFs have been shown to support growth in infants with CMA, similar to other hypoallergenic formulas. Participants recommend healthcare professionals take these statements as guidance to use HRF in clinical practice. Based on efficacy and growth evidence, the experts found HRF a suitable option for the dietary management of CMA.

Conclusion

HRF can be recommended as a first-line alternative to cow's milk-based eHF or AAF, where available, in the dietary management of CMA.

Tolerance to sterilised cow's milk in patients with eosinophilic oesophagitis triggered by milk

BACKGROUND

Cow's milk protein is the main food trigger for eosinophilic oesophagitis (EoE) in children and adults and should be continuously avoided once identified as such.

AIMS

To evaluate tolerance of sterilised cow's milk (boiled instead of UHT processing) with regard to maintenance of EoE remission, health-related quality of life (HRQoL), nutritional intake and allergic sensitisation in patients of all ages with milk-triggered EoE METHODS: We prospectively recruited patients in whom cow's milk was demonstrated to trigger EoE after an empirical food elimination diet-based study. They were given 200 ml of sterilised cow's milk twice daily for 8 weeks. Endoscopic assessment, peak eosinophil counts, oesophageal-related symptoms, HRQoL, blood eosinophils, eosinophil cationic protein (ECP), skin prick test and serum total and specific immunoglobulin E (IgE) to major milk proteins were monitored before and after sterilised milk intake.

RESULTS

Eighteen patients (13 male) in EoE remission underwent a sterilised milk challenge. Twelve maintained EoE remission (<15 eos/hpf) while EoE recurred in the remainder. Endoscopic appearances deteriorated in non-tolerant patients. HRQoL scored well at baseline and was maintained among patients tolerant to sterilised milk, but deteriorated in reactive ones. No significant changes in blood eosinophil count, ECP, tryptase or total and milk-specific IgE serum levels were observed from baseline. However, cow's milk-specific IgE increased slightly in non-tolerant patients. Clinical and histological remission were maintained in patients who regularly consumed sterilised milk for 1 year.

CONCLUSION

Sterilised milk did not trigger EoE in two-thirds of patients with documented milk-induced EoE, in either the short or long term.

Influences on Skeletal Health and Bone Mineralization in Children

Bone is in its most active formation phase of mineralization in the pediatric and adolescent population. Peak bone mass is achieved around the late teens to early 20s. Deficient bone mineralization and decreased peak bone mass acquisition predispose an individual to childhood fractures or lifelong fracture risk. Adolescent fragility or stress fractures should prompt a secondary evaluation for the causes of a low bone mineral content, the root of a fracture. The purpose of this article is to review published literature that discusses the risk factors associated with a decreased bone mineral content in children from birth to the age of peak bone mass. The article also includes a public health planning model for pediatric osteoporosis.

Hypoallergenicity assessment of an extensively hydrolyzed whey-protein formula in cow's milk allergic infants

BACKGROUND

Extensively hydrolyzed formulas are recommended for the dietary management of infants with cow's milk allergy (CMA).

OBJECTIVES

Hypoallergenicity, growth, and gastrointestinal (GI) tolerability of a new extensively hydrolyzed whey-protein formula (eHWF) in CMA children were assessed.

METHODS

In this prospective, randomized, international, multi-center study (Trial NL3889), 34 children with confirmed CMA (74% IgE-mediated) underwent a double-blind, placebo-controlled food challenge (DBPCFC) with an eHWF developed with non-porcine enzymes, supplemented with prebiotic short-chain galacto- and long-chain fructo-oligosaccharides (0.8 g/L, ratio 9:1), arachidonic acid (0.35/100 g), and docosahexaenoic acid (0.35/100 g). If tolerant to the eHWF, children participated in a 7-day open food challenge with this eHWF. Anthropometrics and GI tolerability were assessed in an optional 16-weeks follow-up.

RESULTS

Of the 34 children who started the DBPCFC with the eHWF, 25 subjects (19 boys, mean age: 61 weeks, 18 with IgE-mediated CMA) completed the DBPCFC and 7-day open challenge without major protocol deviations and tested negative at both challenges. One child experienced a late moderate eczematous allergic reaction in the optional follow-up period, indicating the need for close monitoring of subjects starting new formula. Weight and length gain followed the World Health Organization growth curves. Changes in frequency and consistency of stools upon test formula intake were transient.

CONCLUSIONS

The newly developed eHWF is a suitable option in CMA treatment as all subjects tolerated the product. This result is in line with the international criteria for hypoallergenicity (American Academy of Pediatrics) that state that more than 90% of CMA children must tolerate the formula. Use of the formula is also associated with normal growth curves and GI tolerability.

TRIAL REGISTRATION

Trial NL3889, https://www.trialregister.nl/trial/3889.

Evaluation of the complementary feeding practices, dietary intake, and nutritional status of infants on a cow's milk protein elimination diet

OBJECTIVE

To evaluate the complementary feeding practices, food intake, and nutritional status of infants on a cow's milk protein elimination diet.

METHODS

A cross-sectional and observational study was conducted to compare infants aged 4-18 months who were on a cow's milk protein elimination diet with a control group of healthy infants without any dietary restrictions. General information on the child's health, demographic data, and food consumption were collected.

RESULTS

The study included 96 infants in the elimination diet group and 99 in the control group. In the elimination diet group, the median age (in months) of introduction of solid foods (5.0 × 4.0; p < 0.001) and water (5.5 × 4.0; p < 0.05) was later, consumption of soft drinks and industrialized cookies was less frequent (p < 0.05), and a lower index of complementary feeding inadequacies (2.75 × 3.50; p < 0.001) was observed. The elimination diet group presented lower individual values of Z scores for weight/age, weight/height, and body mass index/age, although they were fed with higher amounts of energy (117.4 × 81.3 kcal/kg of weight; p < 0.001) and macro-and micronutrients, except for vitamin A. In the elimination diet group, breast milk and its substitutes contributed to more than 67% of energy intake. Although calcium consumption was a deficit in 31.5% of the infants, none received supplementation.

CONCLUSION

Infants on an elimination diet presented more adequate complementary feeding practices and higher nutritional intake, despite lower body weight values.

Consensus on the diagnosis and treatment of cow's milk protein allergy of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition

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.

Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

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.

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

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.

Growth of infants with gastrointestinal manifestations of cow’s milk protein allergy

ABSTRACT Objective To assess linear growth and weight gain in infants with suspected cow’s milk protein allergy with gastrointestinal manifestations, seen at a gastropediatrics clinic. Methods A retrospective cohort study conducted with demographic, clinical, anthropometric and dietary information on 84 infants first seen between 2015 and 2018 and followed-up for six months. Stature-for-age, weight-for-age, and body mass index-for-age in z-scores were evaluated according to the cut off points established by the World Health Organization in 2006. Accelerated growth or catch-up was considered a gain ?0.67 in the z-score of the referred indices, evaluated at 3 and 6 months. Results Median age at baseline was 4.0 months and 88.1% of the infants were already in diet exclusion. Regarding the anthropometric evaluation short stature frequency was 15.5% and the underweight frequency was 8.3% and 3.6% respectively based on the weight-for-age and body mass index-for-age indices. High recovery growth was observed during the follow-up period but was not considered catch up. In boys, the gains in weight-for-age and body mass index-for-age were significant (p=0.02 and p=0.01 respectively) and close to the threshold that characterizes the catch up, 0.58 and 0.59, respectively. In girls, significant gains in stature-for-age and weight-for-age (0.38 and 0.37 respectively, p=0.02 for both) were observed. Conclusion Infants with suspected cow’s milk protein allergy with gastrointestinal manifestations should have early access to specialized nutritional counseling to avoid exposure to allergenic food and control allergy symptoms, thereby avoiding malnutrition and ensuring adequate nutritional recovery.

Semi-Elemental and Elemental Formulas for Enteral Nutrition in Infants and Children with Medical Complexity-Thinking about Cow's Milk Allergy and Beyond

Children with medical complexities, such as multi-system disorders and/or neurological impairments, often experience feeding difficulties and need enteral nutrition. They frequently have impaired motility and digestive-absorbing functions related to their underlying condition. If a cow's milk allergy (CMA) occurs as a comorbidity, it is often misdiagnosed, due to the symptoms' overlap. Many of the commercialized mixtures intended for enteral nutrition are composed of partially hydrolyzed cow's milk proteins, which are not suitable for the treatment of CMA; thus, the exclusion of a concomitant CMA is mandatory in these patients for obtaining symptoms relief. In this review, we focus on the use of elemental and semi-elemental formulas in children with neurological diseases and in preterm infants as clinical "models" of medical complexity. In children with neurodisabilities, when gastrointestinal symptoms persist despite the use of specific enteral formula, or in cases of respiratory and/or dermatological symptoms, CMA should always be considered. If diagnosis is confirmed, only an extensively hydrolyzed or amino-acid based formula, or, as an alternative, extensively hydrolyzed nutritionally adequate formulas derived from rice or soy, should be used. Currently, enteral formulas tailored to the specific needs of preterm infants and children with neurological impairment presenting concomitant CMA have not been marketed yet. For the proper monitoring of the health status of patients with medical complexity, multidisciplinary evaluation and involvement of the nutritional team should be promoted.

Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy

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.

Hydrolysed Formulas in the Management of Cow's Milk Allergy: New Insights, Pitfalls and Tips

An allergy to cow's milk requires the avoidance of cow's milk proteins and, in some infants, the use of a hypoallergenic formula. This review aims to summarize the current evidence concerning different types of hydrolysed formulas (HF), and recommendations for the treatment of IgE- and non-IgE-mediated cow's milk allergy and functional gastrointestinal disorders in infancy, for which some dietary intervention and HF may be of benefit to both immune and motor mechanisms. Current guidelines recommend cow's milk protein (i.e., whey or casein) extensively hydrolysed formula (eHF) as the first choice for cow's milk allergy treatment, and amino acid formulas for more severe cases or those with reactions to eHF. Rice hydrolysed formulas (rHF) have also become available in recent years. Both eHF and rHF are well tolerated by the majority of children allergic to cow's milk, with no concerns regarding body growth or adverse effects. Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics. Despite encouraging results on tolerance acquisition, evidence is still not conclusive, thus hampering our ability to draw firm conclusions. In clinical practice, the choice of hypoallergenic formula should be based on the infant's age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy.

Associations between the infant and young child feeding index and nutritional status

BACKGROUND

The infant and child feeding index (ICFI) is a single summary World Health Organization influenced index to assess feeding quality in infants and young children aged 6-36 months. This study aimed to demonstrate any associations between ICFI and nutritional status in a single Thai center.

METHODS

The demographic data and feeding practices of healthy infants and children aged 6-36 months were collected from questionnaires given to 304 parents/caregivers; anthropometric measurements were taken. Associations between ICFI and weight-for-age Z scores (WAZ), length/height for age Z scores (LAZ/HAZ), weight-for-length/height Z scores (WLZ/WHZ), and body mass index-for-age Z scores (BAZ) were examined.

RESULTS

The mean ICFI was 6.14 ± 1.63 and was lowest in the 6-8 months age group. Breastfed infants had significantly higher ICFI scores than those not breastfed. Factors influencing ICFI were infant age and milk volume intake. The ICFI was negatively associated with WAZ, WLZ/WHZ, and BAZ (β = -0.13, P = 0.037; β = -0.17, p = 0.01; β = -0.15, P = 0.026, respectively). Breastfeeding was also negatively associated with WAZ, LAZ/HAZ, WLZ/WHZ, and BAZ.

CONCLUSIONS

This study demonstrated a negative association between the ICFI and nutritional status. Breastfeeding may have obscured some positive effects from appropriate feeding practices, while dairy consumption may have hidden negative outcome from inappropriate ones. Despite the ICFI appearing to reflect infant and young child feeding behaviors, using the ICFI alone may not accurately reveal nutritional status.

Calcium daily intake and the efficacy of a training intervention on optimizing calcium supplementation therapy: A clinical audit

BACKGROUND AND AIMS

Calcium is an essential element for human health, with key roles in the prevention and therapy of multifactorial conditions. Calcium dietary intake is often insufficient in the general population. The aim of this study was to perform a clinical audit for general practitioners (GPs) to understand the efficacy of training intervention on doctors' awareness about dietary calcium and supplements.

METHODS AND RESULTS

General practice outpatients were enrolled (Before Clinical Audit, BCA) from the same sanitary district, and calcium dietary intake was evaluated with a validated questionnaire, also collecting information about the consumption of calcium and vitamin D supplements. Then, a training intervention with a frontal lesson and discussion with GPs involved was performed. After one month of this intervention, a second outpatient enrolment was performed (Post Clinical Audit, PCA) in the same general practices to evaluate differences in nutritional suggestions and supplement prescription by GPs. In BCA, the calcium dietary intake was low, with nobody reaching 1000 mg as suggested by the guidelines. Only 6.6% and 24.5% took calcium and vitamin D supplements, respectively; in the PCA, these percentages increased to 28% and 78% for calcium and vitamin D supplements, respectively (p < 0.01 PCA vs BCA). There were no differences in calcium dietary intake between BCA and PCA.

CONCLUSION

Training intervention on GPs was successful to sensitize them regarding calcium intake problems; GPs tended to increase the prescription of supplements but not to suggest changes in dietary habits.

Development of Immunohistochemical Methods for Casein Detection in Meat Products

To increase production efficiency of meat products, milk protein additives are often used. Despite a number of advantages, use of dairy ingredients involves a certain risk, namely the allergenic potential of milk proteins. A number of methods have been developed to detect milk-origin raw materials in foodstuffs, including immunological reference methods. This study presents newly developed immunohistochemical (IHC) methods for casein detection in meat products. Casein was successfully detected directly in meat products where sensitivity was determined at 1.21 and specificity at 0.28. The results obtained from the IHC were compared with the Enzyme-Linked Immuno Sorbent Assay (ELISA) and there was no statistically significant difference between the IHC and ELISA methods (p > 0.05). The correspondence between the methods was 72% in total. The highest correspondence was reached in frankfurters (90%), the lowest in canned pâté (44%).

CASE-CONTROL STUDY ON VITAMIN D STATUS IN CHILDREN AND ADOLESCENTS WITH EOSINOPHILIC ESOPHAGITIS

BACKGROUND

Vitamin D is an essential fat-soluble steroid hormone and vitamin D deficiency is a global public health problem especially among children and adolescents. Factors such as the low intake of vitamin D-rich food sources, poor absorption and less exposure to the sun influence this outcome. Vitamin D has an anti-inflammatory effect in the body by promoting regulatory T cell differentiation as well as recovering T helper 17 cell response and secretion of anti-inflammatory cytokines. Eosinophilic esophagitis (EoE) is a chronic disease, histologically characterized by predominantly eosinophilic inflammation. The most common therapeutic approaches are allergen-eliminating diets, such as excluding cow's milk, egg, soy, wheat, peanuts and seafood, or more specific dietary restrictions.

OBJECTIVE

To verify the serum levels of vitamin D in children and adolescents with eosinophilic esophagitis on a restricted food diet and to analyze their association with nutritional status, consumption of different food sources, exposure to the sun and skin color.

METHODS

Case-control study conducted in the city of Campinas-SP, Brazil, in which included patients were aged 2 to 18 years old, and those diagnosed with eosinophilic esophagitis was referred to as the case group (n=15), meanwhile a control group (n=17) was also formed. Epidemiological data, nutritional status, data on vitamin D intake (24-hour recall - performed only by EoE patients - and self-reported intake of vitamin D food sources: milk and dairy products, canned tuna and sardines, Bull's liver, chicken eggs - applied in both groups), and daily time of sun exposure (≥30 min or ≤30 min) were recorded. The samples were collected for serum levels of 25-hydroxy-vitamin D, where sufficiency levels >30 ng/mL were considered, insufficiency 21 to 30 ng/mL, deficiency <20 ng/mL.

RESULTS

There was a higher frequency of vitamin D insufficiency/ deficiency in the Eosinophilic Esophagitis group (P=0.035), even with longer sun exposure (P= 0.035). Skin color was not associated with lower levels of vitamin D in both groups studied. No difference was found in nutritional status between the groups.

CONCLUSION

The present study demonstrated a higher frequency of inadequate/ deficient levels of vitamin D in children and adolescents with EoE on a restricted diet. When necessary, serum levels should be investigated and correct exposure to the sun should be encouraged, with special attention to the recommended guidelines, time spent in the sun and the appropriate clothing for correct absorption. Since exposure for more than 30 minutes in the sun does not appear to have provided a protective effect in the EoE group, even in a region with high levels of solar radiation. There was a significant difference only in the consumption of cow's milk between the case and control groups, demonstrating the low adherence to the restriction diet by the case group. No association was found between serum 25 hydroxyvitamin D levels and nutritional status. Moreover, no association regarding the adequate or inadequate status of 25 hydroxyvitamin D and the consumption vitamin D-rich foods was identified. Multicentered studies with a larger number of cases should be performed to assess serum 25 hydroxyvitamin D levels and associated factors in pediatric patients with EoE.

Hydrolyzed Rice Protein-Based Formulas, a Vegetal Alternative in Cow's Milk Allergy

Formulas adapted to infant feeding, although most of the time made from cow's milk proteins, can be made from hydrolyzed rice protein but they must be classified as "formulas for specific medical needs", according to European regulations. The nutritional quality of rice proteins is thus suitable to be used in infant formulas giving that it is supplemented by certain amino acids which can be lacking. Besides, hydrolysis is required to facilitate their water solubility and digestibility. Owing to a low allergenicity of rice and to the absence of the cross-allergy between milk proteins and rice proteins, these formulas are adapted to the diet of children with cow's milk protein allergy (CMPA), which explains their growing use in some countries. However, CMPA, an expanding disorder, has consequences for growth, bone mineralization, and often has an association with allergy to other foods, including cow's milk extensive hydrolysate, so that a surveillance of the adaption of hydrolyzed rice protein formulas (HRPF) to CMPA, the absence of unexpected side effects, and the appropriate response to its various health hazards seems mandatory. This paper analyses the health problem deriving from CMPA, the industrial development of hydrolyzed rice protein formulas, and the limited number of clinical studies, which confirms, at the moment, a good allergic tolerance and safety. The goal is to better advise heath care professionals on their use of HRPFs during CMPA.

Hypoallergenicity of a thickened hydrolyzed formula in children with cow's milk allergy

BACKGROUND

Allergy to cow's milk is the most frequent allergy occurring in infants and young children. The dietary management of these patients consists of the elimination of any cow's milk proteins from the diet, and for formula-fed infants, the substitution of the usual infant formula with an adapted formula that is generally based on extensively hydrolyzed cow's milk proteins. The American Academy of Pediatrics has established specific criteria to confirm the hypoallergenicity of a formula intended for these children.

AIM

To assess the hypoallergenicity of a new thickened extensively hydrolyzed casein-based formula (TeHCF) in children with cow's milk allergy (CMA).

METHODS

Children diagnosed with CMA through a double-blind placebo-controlled food challenge (DBPCFC) were randomly administered increased doses of a placebo formula or the TeHCF [Allernova, new thickener including fibres (Novalac)] under double-blind conditions and medical surveillance on two separate days. Otherwise, both of these formulas and a cow's milk-based formula were randomly introduced to children who were highly suspected of having CMA on three separate days. Immediate and late reactions occurring after the introduction of any of these formulas were thoroughly recorded by the physician at the hospital and reported by parents to the physician after hospital discharge, respectively. If the children tolerated the TeHCF during the DBPCFC, they were exclusively fed this formula during a 3-mo period where potential allergic symptoms, anthropometric parameters, as secondary outcomes, and adverse events were registered. The Cow's Milk-related Symptoms Score (CoMiSSTM) was assessed and anthropometric parameters were compared to World Health Organization (WHO) reference data.

RESULTS

Of the 30 children included in the study, the CMA diagnosis of 29 (mean age: 8.03 ± 7.43 mo) patients was confirmed by a DBPCFC. The children all tolerated the TeHCF during both the challenge and the subsequent 3-mo feeding period, which they all completed. During the latter period, the CoMiSSTM remained at a very low level, never exceeding its baseline value (1.4 ± 2.0), growth parameters were within WHO reference standards and no adverse event related to the TeHCF was reported. Over the first week of this period, the proportion of patients with digestive discomfort significantly decreased from 20.7% (6/29) to 3.4% (1/29), P = 0.025. The proportion of satisfaction with the overall effect of the formula reported by the parents and investigator was high, as was the formula acceptability by the child.

CONCLUSION

The new TeHCF meets the hypoallergenicity criteria according to the American Academy of Pediatrics standards, confirming that the tested TeHCF is adapted to the dietary management of children with CMA. Moreover, growth was adequate in the included population.

Molecular Approaches for Diagnosis, Therapy and Prevention of Cow´s Milk Allergy

Cow´s milk is one of the most important and basic nutrients introduced early in life in our diet but can induce IgE-associated allergy. IgE-associated allergy to cow´s milk can cause severe allergic manifestations in the gut, skin and even in the respiratory tract and may lead to life-threatening anaphylactic shock due to the stability of certain cow´s milk allergens. Here, we provide an overview about the allergen molecules in cow´s milk and the advantages of the molecular diagnosis of IgE sensitization to cow´s milk by serology. In addition, we review current strategies for prevention and treatment of cow´s milk allergy and discuss how they could be improved in the future by innovative molecular approaches that are based on defined recombinant allergens, recombinant hypoallergenic allergen derivatives and synthetic peptides.