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Fiocchi A, Schunemann H, Ansotegui I, Assa’ad A, Bahna S, Canani RB, Bozzola M, Dahdah L, Dupont C, Ebisawa M, Galli E, Li H, Kamenwa R, Lack G, Martelli A, Pawankar R, Said M, Sánchez-Borges M, Sampson H, Shamir R, Spergel J, Terracciano L, Vandenplas Y, Venter C, Waserman S, Wong G, Brozek J. The global impact of the DRACMA guidelines cow's milk allergy clinical practice. World Allergy Organ J 2018; 11:2. [PMID: 29308116 PMCID: PMC5753480 DOI: 10.1186/s40413-017-0179-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 12/06/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The 2010 Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines are the only Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for cow's milk allergy (CMA). They indicate oral food challenge (OFC) as the reference test for diagnosis, and suggest the choice of specific alternative formula in different clinical conditions. Their recommendations are flexible, both in diagnosis and in treatment. OBJECTIVES & METHODS Using the Scopus citation records, we evaluated the influence of the DRACMA guidelines on milk allergy literature. We also reviewed their impact on successive food allergy and CMA guidelines at national and international level. We describe some economic consequences of their application. RESULTS DRACMA are the most cited CMA guidelines, and the second cited guidelines on food allergy. Many subsequent guidelines took stock of DRACMA's metanalyses adapting recommendations to the local context. Some of these chose not to consider OFC as an absolute requirement for the diagnosis of CMA. Studies on their implementation show that in this case, the treatment costs may increase and there is a risk of overdiagnosis. Interestingly, we observed a reduction in the cost of alternative formulas following the publication of the DRACMA guidelines. CONCLUSIONS DRACMA reconciled international differences in the diagnosis and management of CMA. They promoted a cultural debate, improved clinician's knowledge of CMA, improved the quality of diagnosis and care, reduced inappropriate practices, fostered the efficient use of resources, empowered patients, and influenced some public policies. The accruing evidence on diagnosis and treatment of CMA necessitates their update in the near future.
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Affiliation(s)
- Alessandro Fiocchi
- Division of Allergy, Department of Pediatrics, Pediatric Hospital Bambino Gesù, Piazza Sant’Onofrio, Vatican City, Rome Italy
| | - Holger Schunemann
- Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
| | - Ignacio Ansotegui
- Department of Allergy & Immunology, Hospital Quironsalud Bizkaia, Carretera Leioa-Unbe 33 bis, 48950 Erandio - Bilbao, Spain
| | - Amal Assa’ad
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Sami Bahna
- Pediatrics & Medicine, Allergy & Immunology, Louisiana State University Health Sciences Center, Shreveport, LA USA
| | - Roberto Berni Canani
- Department of Translational Medical Science, European Laboratory for Investigation of Food Induced Diseases and CEINGE Advanced Biotechnology, University of Naples Federico II, Naples, Italy
| | - Martin Bozzola
- Department of Pediatrics, British Hospital, Perdriel 74, CABA, Buenos Aires, Argentina
| | - Lamia Dahdah
- Division of Allergy, Department of Pediatrics, Pediatric Hospital Bambino Gesù, Piazza Sant’Onofrio, Vatican City, Rome Italy
| | - Christophe Dupont
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Hôpital Necker Enfants Malades, Paris, France
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Elena Galli
- Pediatric Allergy Unit, Research Center, San Pietro Hospital - Fatebenefratelli, Rome, Italy
| | - Haiqi Li
- Pediatric Division, Department of Primary Child Care, Children’s Hospital, Chongqing Medical University, Chongqing, China
| | - Rose Kamenwa
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Gideon Lack
- King’s College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Paediatric Allergy, St Thomas’ Hospital, London, UK
| | | | - Ruby Pawankar
- Department of Otolaryngology, Nippon Medical School, 1-1-5 Sendagi, Tokyo, 113 Japan
| | - Maria Said
- Allergy & Anaphylaxis Australia (A&AA) organisation, Sydney, Australia
| | - Mario Sánchez-Borges
- Department of Allergy and Clinical Immunology Centro Médico-Docente La Trinidad Caracas, Caracas, Venezuela
| | - Hugh Sampson
- Department of Pediatrics, Jaffe Food Allergy Institute, New York, USA
- Icahn School of Medicine at Mount Sinai, Box 1089, New York, USA
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children’s Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jonathan Spergel
- Division of Allergy and Immunology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA USA
| | - Luigi Terracciano
- National Pediatric Healthcare System, Board member of the Italian Pediatric Respiratory Society, ATS, Milan, Italy
| | - Yvan Vandenplas
- Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Carina Venter
- Section of Allergy & Immunology, University of Colorado Denver School of Medicine | Children’s Hospital Colorado, Aurora, CO USA
| | - Susan Waserman
- Department of Medicine, Clinical Immunology and Allergy, McMaster University, Hamilton, ON Canada
| | - Gary Wong
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Jan Brozek
- Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1200 Main Street West, Hamilton, ON L8N 3Z5 Canada
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