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Meyer R, Vandenplas Y, Lozinsky AC, Vieira MC, Berni Canani R, du Toit G, Dupont C, Giovannini M, Uysal P, Cavkaytar O, Knibb R, Fleischer DM, Nowak-Wegrzyn A, Venter C. Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper. Pediatr Allergy Immunol 2024; 35:e14163. [PMID: 38825829 DOI: 10.1111/pai.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/10/2024] [Indexed: 06/04/2024]
Abstract
The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.
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Affiliation(s)
- Rosan Meyer
- Department of Nutrition and Dietetics, University of Winchester, Winchester, UK
- Department of Medicine, KU Leuven, Leuven, Belgium
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Adriana Chebar Lozinsky
- Department of Allergy and Immune Disorders, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Mario C Vieira
- Center for Pediatric Gastroenterology - Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Roberto Berni Canani
- Department of Translational Medical Science and ImmunoNutritionLab at CEINGE - Advanced Biotechnologies Research Center, University of Naples "Federico II", Naples, Italy
| | - George du Toit
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Christophe Dupont
- Department of Paediatric Gastroenterology, Necker University Children Hospital, Paris, France
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Pinar Uysal
- Department of Allergy and Clinical Immunology, Adnan Menderes University, Aydin, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Prof Suleyman Yalcin City Hospital, Istanbul, Turkey
| | - Rebecca Knibb
- School of Psychology, Aston University, Birmingham, UK
| | - David M Fleischer
- University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anna Nowak-Wegrzyn
- Icahn School of Medicine at Mount Sinai, Jaffe Food Allergy Institute, New York, New York, USA
| | - Carina Venter
- University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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Vandenplas Y, Broekaert I, Domellöf M, Indrio F, Lapillonne A, Pienar C, Ribes-Koninckx C, Shamir R, Szajewska H, Thapar N, Thomassen RA, Verduci E, West C. An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy. J Pediatr Gastroenterol Nutr 2024; 78:386-413. [PMID: 38374567 DOI: 10.1097/mpg.0000000000003897] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/25/2023] [Indexed: 07/27/2023]
Abstract
A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Flavia Indrio
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France
- CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Corina Pienar
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Gastroenterology and Hepatology & Instituto de Investigacion Sanitaria, La Fe University Hospital, Valencia, Spain
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rut Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Christina West
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Darma A, Sumitro KR, Jo J, Sitorus N. Lactose Intolerance versus Cow's Milk Allergy in Infants: A Clinical Dilemma. Nutrients 2024; 16:414. [PMID: 38337698 PMCID: PMC10856892 DOI: 10.3390/nu16030414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/06/2024] [Accepted: 01/12/2024] [Indexed: 02/12/2024] Open
Abstract
Due to its very early introduction, cow's milk is one of the first foods that can cause adverse reactions in human beings. Lactose intolerance (LI) and cow's milk allergy (CMA) are the most common adverse reactions to cow's milk. While LI is due to insufficient small intestinal lactase activity and/or a large quantity of ingested lactose, CMA is an aberrant immune reaction to cow's milk proteins, particularly casein or β-lactoglobulin. However, the clinical manifestations of LI and CMA, particularly their gastrointestinal signs and symptoms, are very similar, which might lead to misdiagnosis or delayed diagnosis as well as nutritional risks due to inappropriate dietary interventions or unnecessary dietary restriction. Formula-fed infants with LI should be treated with formula with reduced or no lactose, while those with CMA should be treated with formula containing extensive hydrolyzed cow's milk protein or amino acids. This review is therefore written to assist clinicians to better understand the pathophysiologies of LI and CMA as well as to recognize the similarities and differences between clinical manifestations of LI and CMA.
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Affiliation(s)
- Andy Darma
- Department of Child Health, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia;
- Department of Child Health, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| | - Khadijah Rizky Sumitro
- Department of Child Health, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia;
- Department of Child Health, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| | - Juandy Jo
- Department of Biology, Faculty of Science and Technology, Universitas Pelita Harapan, Tangerang 15811, Indonesia;
- Mochtar Riady Institute for Nanotechnology, Tangerang 15811, Indonesia
| | - Nova Sitorus
- Danone Specialized Nutrition Indonesia, Jakarta 12940, Indonesia;
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Bakry SM, Banoun Z, Abdulfattah A, Alkhatib F, Almhmadi M, Alharbi M, Alluhaybi A, Krenshi MO, Alharthi F, Ekram S. Comparison of Knowledge of Lactose Intolerance and Cow's Milk Allergy Among the Medical Students at Two Universities in Saudi Arabia. Cureus 2023; 15:e50326. [PMID: 38155979 PMCID: PMC10754492 DOI: 10.7759/cureus.50326] [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] [Accepted: 12/11/2023] [Indexed: 12/30/2023] Open
Abstract
Lactose intolerance is a condition causing an inability to absorb and digest lactose leading to gastrointestinal symptoms such as abdominal pain, diarrhea, and flatulence. Because of the similarities between lactose intolerance and cow's milk allergy, it is becoming necessary to increase physicians' understanding of these two diseases. Consequently, we aimed to determine the level of knowledge of lactose intolerance and cow's milk allergy among medical students. An electronic survey was distributed to 399 medical students at two universities in Saudi Arabia from October to November 2022. The majority of the respondents had an inadequate knowledge of both lactose intolerance and cow's milk allergy (99.75% and 97.99%, respectively). According to the study's results that showed a lack of awareness among health-related students, further studies and awareness programs are highly recommended.
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Affiliation(s)
- Salah M Bakry
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Ziad Banoun
- Department of Medicine and Surgery, College of Medicine, King Abdulaziz University, Makkah, SAU
| | - Ammar Abdulfattah
- Department of Medicine and Surgery, College of Medicine, King Abdulaziz University, Makkah, SAU
| | - Fawaz Alkhatib
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Mussad Almhmadi
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Mohammed Alharbi
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Adel Alluhaybi
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Mohammed O Krenshi
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Fahad Alharthi
- Department of Medicine and Surgery, College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Samar Ekram
- Department of Medical Genetics, College of Medicine, Umm Al-Qura University, Makkah, SAU
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Martínez-Lentisco MDM, Martín-González M, García-Torrecillas JM, Antequera-Soler E, Chillón-Martínez R. Osteopathic Manual Therapy for Infant Colic: A Randomised Clinical Trial. Healthcare (Basel) 2023; 11:2600. [PMID: 37761797 PMCID: PMC10531355 DOI: 10.3390/healthcare11182600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Infant colic is a multifactorial syndrome for which various therapeutic strategies have been proposed. In this study, we evaluate the effectiveness of osteopathic manual therapy in treating symptoms related to infant colic. METHOD A prospective, randomised, blinded clinical trial was conducted of patients diagnosed with infant colic. The treatment group were given osteopathic manual therapy, and their parents received two sessions of counselling. The control group received no such therapy, but their parents attended the same counselling sessions. The non-parametric Mann-Whitney U test was applied to determine whether there were significant differences between the groups for the numerical variables considered. For the qualitative variables, Fisher's exact test was used. The threshold assumed for statistical significance was 0.05. RESULTS A total of 42 babies were assigned to each group. Those in the experimental group presented less severe infant colic with a trend towards statistical significance after the first session (p = 0.09). In sucking, excretion, eructation and gas there were no significant differences between the groups. Crying was a statistically significant dimension both after the first intervention (p = 0.03) and two weeks after (p = 0.04). Regurgitation values were significantly lower in the experimental group during the three weeks of follow-up (p = 0.05). Values for sleep were lower in the experimental group, but the differences were not statistically significant. In both groups, colic severity decreased over time, with no side effects. CONCLUSIONS Treatment with osteopathic manual therapy alleviates the symptoms of infant colic and could be recommended for this purpose from the onset of the condition.
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Affiliation(s)
- María del Mar Martínez-Lentisco
- Andalusian Health Service, Almería Health District, 04002 Almería, Spain
- Department of Nursing Science, Physiotherapy and Medicine, University of Almería, 04120 Almería, Spain; (M.M.-G.); (E.A.-S.)
| | - Manuel Martín-González
- Department of Nursing Science, Physiotherapy and Medicine, University of Almería, 04120 Almería, Spain; (M.M.-G.); (E.A.-S.)
- Torrecárdenas University Hospital, 04009 Almería, Spain
| | - Juan Manuel García-Torrecillas
- Emergency and Research Unit, Torrecárdenas University Hospital, 04009 Almería, Spain;
- CIBER de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Instituto de Investigación Biosanitaria Ibs, 18012 Granada, Spain
| | - Eduardo Antequera-Soler
- Department of Nursing Science, Physiotherapy and Medicine, University of Almería, 04120 Almería, Spain; (M.M.-G.); (E.A.-S.)
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Alghasham YA, Alharbi AM, Alhumaidi KA, Alkhalifah YS. Primary Healthcare Center's Healthcare Providers' Perception and Practice Toward Pediatric Cow's Milk Allergy in Qassim Region, Saudi Arabia. Cureus 2023; 15:e41719. [PMID: 37575801 PMCID: PMC10414770 DOI: 10.7759/cureus.41719] [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] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Cow's milk allergy (CMA) typically first manifests in the first year of life, and it is the most challenging food allergy to detect since the clinical symptoms can vary significantly in both types and severity. This study is carried out to evaluate the level of knowledge and practice of healthcare providers (HCPs) in the Qassim Region regarding CMA. RESEARCH METHODOLOGY This is a cross-sectional study conducted among HCPs in the Qassim Region, Saudi Arabia. A self-administered questionnaire was distributed among HCPs using face-to-face interviews compromising four governorates of Qassim such as Buraydah, Unaizah, AlRass, and Albukairyah. The questionnaire includes socio-demographic characteristics and questions to assess the knowledge and practice of HCPs regarding CMA. RESULTS Among 124 HCPs, 29% were aged between 25 and 30 years, 50.8% were males and 49.2% were females. Over three-quarters (77.4%) were categorized as having poor knowledge levels, while poor practice was also prevalent (83.1%). Factors associated with increased knowledge and practice were being non-Saudi, being a consultant/specialist, and having more than 10 years of experience. There was a significant positive correlation between knowledge and practice scores (p<0.001). CONCLUSION The knowledge and practice of HCPs regarding CMA were insufficient. Non-Saudi consultants/specialists with more years of experience tend to be more knowledgeable and have better skills in managing the disease. Further longitudinal studies are required to establish the level of knowledge and practices toward CMA.
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Affiliation(s)
- Yazeed A Alghasham
- Department of Pediatrics, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, SAU
| | - Aeshah M Alharbi
- College of Medicine, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, SAU
| | - Kadi A Alhumaidi
- College of Medicine, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, SAU
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Meyer R, Venter C, Bognanni A, Szajewska H, Shamir R, Nowak-Wegrzyn A, Fiocchi A, Vandenplas Y. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guideline update - VII - Milk elimination and reintroduction in the diagnostic process of cow's milk allergy. World Allergy Organ J 2023; 16:100785. [PMID: 37546235 PMCID: PMC10401347 DOI: 10.1016/j.waojou.2023.100785] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 08/08/2023] Open
Abstract
The diagnosis of cow's milk allergy (CMA) in infants and young children remains a challenge because many of the presenting symptoms are similar to those experienced in other diagnoses. Both over- and under-diagnosis occur frequently. Misdiagnosis carries allergic and nutritional risks, including acute reactions, growth faltering, micronutrient deficiencies and a diminished quality of life for infants and caregivers. An inappropriate diagnosis may also add a financial burden on families and on the healthcare system. Elimination and reintroduction of cow's milk (CM) and its derivatives is essential for diagnosing CMA as well as inducing tolerance to CM. In non-IgE mediated CMA, the diagnostic elimination diet typically requires 2-4 weeks before reintroduction, while for IgE mediated allergy the time window may be shorter (1-2 weeks). An oral food challenge (OFC) under medical supervision remains the most reliable diagnostic method for IgE mediated and more severe types of non-IgE mediated CMA such as food protein induced enterocolitis syndrome (FPIES). Conversely, for other forms of non-IgE mediated CMA, reintroduction can be performed at home. The OFC cannot be replaced by the milk ladder after a diagnostic elimination diet. The duration of the therapeutic elimination diet, once a diagnosis was confirmed, can only be established through testing changes in sensitization status, OFCs or home reintroduction, which are directed by local protocols and services' availability. Prior non-evidence-based recommendations suggest that the first therapeutic elimination diet should last for at least 6 months or up to the age of 9-12 months, whichever is reached first. After a therapeutic elimination diet, a milk-ladder approach can be used for non-IgE mediated allergies to determine tolerance. Whilst some centers use the milk ladder also for IgE mediated allergies, there are concerns about the risk of having immediate-type reactions at home. Milk ladders have been adapted to local dietary habits, and typically start with small amounts of baked milk which then step up in the ladder to less heated and fermented foods, increasing the allergenicity. This publication aims to narratively review the risks associated with under- and over-diagnosis of CMA, therefore stressing the necessity of an appropriate diagnosis and management.
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Affiliation(s)
- Rosan Meyer
- Faculty Medicine, Imperial College London, Department Nutrition and Dietetics, Winchester University, UK and Faculty Medicine, KU Leuven, Belgium
| | - Carina Venter
- Children's Hospital Colorado, University of Colorado, Denver, CO, USA
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Evidence in Allergy Group; Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Anna Nowak-Wegrzyn
- Hassenfeld Children's Hospital, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA
| | - Alessandro Fiocchi
- Allergy Unit - Area of Translational Research in Pediatric Specialities, Bambino Gesù Children's Hospital, Rome, Italy
| | - Yvan Vandenplas
- Vrije Universiteit Brussel, UZ Brussel, KidZ Health Castle, Brussels, Belgium
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Madrazo JA, Alrefaee F, Chakrabarty A, de Leon JC, Geng L, Gong S, Heine RG, Järvi A, Ngamphaiboon J, Ong C, Rogacion JM. International Cross-Sectional Survey among Healthcare Professionals on the Management of Cow's Milk Protein Allergy and Lactose Intolerance in Infants and Children. Pediatr Gastroenterol Hepatol Nutr 2022; 25:263-275. [PMID: 35611371 PMCID: PMC9110852 DOI: 10.5223/pghn.2022.25.3.263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/22/2021] [Accepted: 03/07/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The present international survey among healthcare providers aimed to collect data on theoretical knowledge and clinical practices in the diagnosis and management of cow's milk protein allergy (CMPA) and lactose intolerance (LI) in infants. METHODS A global survey was conducted in several countries with diverse health care settings. The survey consisted of multiple-choice questions in 3 main domains: (1) understanding and clinical practices around CMPA and LI; (2) case scenarios; and (3) disease-specific knowledge and potential educational needs. RESULTS Responses were available from 1,663 participants. About 62% of respondents were general practitioners or general pediatricians, and the remainder were pediatric allergists/gastroenterologists (18%) or other health practitioners (20%). The survey identified knowledge gaps regarding the types of CMPA (IgE-mediated vs. non-IgE-mediated) and the clinical overlap with LI. The survey suggested diverse clinical practices regarding the use of hypoallergenic formulas, as well as misconceptions about the prebiotic benefits of lactose in extensively hydrolyzed formulas in non-breastfed infants with CMPA. Responses to the two case scenarios highlighted varying levels of awareness of the relevant clinical practice guidelines. While respondents generally felt confident in managing infants with CMPA and LI, about 80% expressed an interest for further training in this area. CONCLUSION The current survey identified some knowledge gaps and regional differences in the management of infants with CMPA or LI. Local educational activities among general and pediatric healthcare providers may increase the awareness of clinical practice guidelines for the diagnosis and treatment of both conditions and help improve clinical outcomes.
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Affiliation(s)
- J Armando Madrazo
- Department of Pediatrics, Universidad Nacional Autónoma de México, México City, México
| | - Fawaz Alrefaee
- Pediatric Department, Al Adan Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Anjan Chakrabarty
- Department of Paediatrics, West Middlesex University Hospital, Isleworth, United Kingdom
| | - Julia C de Leon
- Department of Pediatrics, Cardinal Santos Medical Center, Manila, Philippines
| | - Lanlan Geng
- Department of Gastroenterology, Guangzhou Women's and Children's Medical Center, Guangzhou, China
| | - Sitang Gong
- Department of Pediatrics, Guangzhou Women's and Children's Medical Center, Guangzhou, China
| | | | | | | | - Christina Ong
- Department of Paediatric Gastroenterology, KK Women's and Children's Hospital, Singapore
| | - Jossie M Rogacion
- Department of Pediatrics, University of the Philippines, Philippine General Hospital, Manila, Philippines
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9
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Fiocchi A, Bognanni A, Brożek J, Ebisawa M, Schünemann H. 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] [Key Words] [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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Affiliation(s)
- Alessandro Fiocchi
- Translational Research in Pediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Jan Brożek
- Department of Medicine, Division of Clinical Immunology and Allergy, Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, Hamilton, ON, Canada
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Kanagawa, Japan
| | - Holger Schünemann
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Cochrane Canada and McMaster GRADE Centre, Hamilton, Ontario, Canada
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Di Costanzo M, Biasucci G, Maddalena Y, Di Scala C, De Caro C, Calignano A, Canani RB. Lactose Intolerance in Pediatric Patients and Common Misunderstandings About Cow's Milk Allergy. Pediatr Ann 2021; 50:e178-e185. [PMID: 34039171 DOI: 10.3928/19382359-20210312-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lactose intolerance is a common gastrointestinal condition caused by the inability to digest and absorb dietary lactose. Primary lactose intolerance is the most common type of lactose intolerance. It is one of the most common forms of food intolerance and occurs when lactase activity is reduced in the brush border of the small bowel mucosa. People may be lactose intolerant to varying degrees, depending on the severity of these symptoms. When lactose is not digested, it is fermented by gut microbiota, leading to abdominal pain, bloating, flatulence, and diarrhea with a considerable intraindividual and interindividual variability in the severity of clinical manifestations. These gastrointestinal symptoms are similar to cow's milk allergy and could be wrongly labeled as symptoms of "milk allergy." There are important differences between lactose intolerance and cow's milk allergy. Therefore, a better knowledge of these differences could limit misunderstandings in the diagnostic approach and in the management of these conditions. [Pediatr Ann. 2021;50(4):e178-e185.].
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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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Heine RG, AlRefaee F, Bachina P, De Leon JC, Geng L, Gong S, Madrazo JA, Ngamphaiboon J, Ong C, Rogacion JM. Lactose intolerance and gastrointestinal cow's milk allergy in infants and children - common misconceptions revisited. World Allergy Organ J 2017; 10:41. [PMID: 29270244 PMCID: PMC5726035 DOI: 10.1186/s40413-017-0173-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/15/2017] [Indexed: 02/07/2023] Open
Abstract
Lactose is the main carbohydrate in human and mammalian milk. Lactose requires enzymatic hydrolysis by lactase into D-glucose and D-galactose before it can be absorbed. Term infants express sufficient lactase to digest about one liter of breast milk daily. Physiological lactose malabsorption in infancy confers beneficial prebiotic effects, including the establishment of Bifidobacterium-rich fecal microbiota. In many populations, lactase levels decline after weaning (lactase non-persistence; LNP). LNP affects about 70% of the world’s population and is the physiological basis for primary lactose intolerance (LI). Persistence of lactase beyond infancy is linked to several single nucleotide polymorphisms in the lactase gene promoter region on chromosome 2. Primary LI generally does not manifest clinically before 5 years of age. LI in young children is typically caused by underlying gut conditions, such as viral gastroenteritis, giardiasis, cow’s milk enteropathy, celiac disease or Crohn’s disease. Therefore, LI in childhood is mostly transient and improves with resolution of the underlying pathology. There is ongoing confusion between LI and cow’s milk allergy (CMA) which still leads to misdiagnosis and inappropriate dietary management. In addition, perceived LI may cause unnecessary milk restriction and adverse nutritional outcomes. The treatment of LI involves the reduction, but not complete elimination, of lactose-containing foods. By contrast, breastfed infants with suspected CMA should undergo a trial of a strict cow’s milk protein-free maternal elimination diet. If the infant is not breastfed, an extensively hydrolyzed or amino acid-based formula and strict cow’s milk avoidance are the standard treatment for CMA. The majority of infants with CMA can tolerate lactose, except when an enteropathy with secondary lactase deficiency is present.
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Affiliation(s)
- Ralf G Heine
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Fawaz AlRefaee
- Al Adan Hospital, Ministry of Health, Kuwait City, Kuwait
| | | | - Julie C De Leon
- Philippine Society of Allergy, Asthma & Immunology, Philippine Medical Association, Quezon City, Philippines
| | - Lanlan Geng
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Sitang Gong
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - José Armando Madrazo
- Universidad National Autonoma de México, Hospital Infantil Privado Star Médica, Polanco, Mexico City, Mexico
| | | | - Christina Ong
- KK Women's and Children's Hospital and Yong Loo Lin School of Medicine and Duke-NUS Medical School, Singapore, Singapore
| | - Jossie M Rogacion
- University of the Philippines, Philippine General Hospital, Manila, Philippines
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Netts P, Michaelis LJ. An interpretation of the new international MAP guideline for the management of Milk Allergy in Primary Care. Clin Transl Allergy 2017; 7:34. [PMID: 28948011 PMCID: PMC5609207 DOI: 10.1186/s13601-017-0171-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 09/16/2017] [Indexed: 12/25/2022] Open
Abstract
General Practitioners suffer from guideline fatigue. They come fast and furious in many complicated forms. Cow's milk allergy (CMA) is one of the most common presentations of food allergy seen in early childhood presenting to primary and secondary care. The early and accurate diagnosis continues to be highlighted in many countries worldwide. International surveys have found that primary care clinicians would like clearer explanations for the options for the diagnosis of CMA and in so doing a means to increase their understanding of management options for both IgE and Non IgE mediated CMA. In 2013 in response to General Practitioner demands, the UK guideline, 'Diagnosis and management of non-IgE-mediated CMA in infancy-a UK primary care practical guide' was published in this journal. This Milk Allergy in Primary Care (MAP) guideline outlines in simple algorithmic form how to diagnose, manage and refer children with CMA in a primary care setting. Based on the international uptake of the MAP guideline, a global practical guideline International MAP is presented by the Venter and Brown et al to help practitioners in primary care settings. It incorporates further published UK guidance, feedback from UK healthcare professionals and affected families and, importantly, also international guidance and expertise.
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Affiliation(s)
- Paul Netts
- Benfield Park Medical Group, Newcastle Upon Tyne, NE6 4QD UK
| | - Louise J. Michaelis
- Department of Paediatric Allergy, Great North Children’s Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE1 4LP UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, UK
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Venter C, Brown T, Meyer R, Walsh J, Shah N, Nowak-Węgrzyn A, Chen TX, Fleischer DM, Heine RG, Levin M, Vieira MC, Fox AT. Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy 2017; 7:26. [PMID: 28852472 PMCID: PMC5567723 DOI: 10.1186/s13601-017-0162-y] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 06/30/2017] [Indexed: 12/18/2022] Open
Abstract
Cow's milk allergy (CMA) is one of the most common presentations of food allergy seen in early childhood. It is also one of the most complex food allergies, being implicated in IgE-mediated food allergy as well as diverse manifestations of non-IgE-mediated food allergy. For example, gastrointestinal CMA may present as food protein induced enteropathy, enterocolitis or proctocolitis. Concerns regarding the early and timely diagnosis of CMA have been highlighted over the years. In response to these, guideline papers from the United Kingdom (UK), Australia, Europe, the Americas and the World Allergy Organisation have been published. The UK guideline, 'Diagnosis and management of non-IgE-mediated cow's milk allergy in infancy-a UK primary care practical guide' was published in this journal in 2013. This Milk Allergy in Primary Care (MAP) guideline outlines in simple algorithmic form, both the varying presentations of cow's milk allergy and also focuses on the practical management of the most common presentation, namely mild-to-moderate non-IgE-mediated allergy. Based on the international uptake of the MAP guideline, it became clear that there was a need for practical guidance beyond the UK. Consequently, this paper presents an international interpretation of the MAP guideline to help practitioners in primary care settings around the world. It incorporates further published UK guidance, feedback from UK healthcare professionals and affected families and, importantly, also international guidance and expertise.
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Affiliation(s)
- Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children’s Hospital Colorado , Box B518, 13123 East 16th Avenue, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Trevor Brown
- Children’s Allergy Service, Ulster Hospital, Belfast, BT16 1RH Northern Ireland, UK
| | - Rosan Meyer
- Department Paediatrics, Imperial College, London, London, W2 1NY UK
| | - Joanne Walsh
- Gurney Surgery, Castle Partnership, 101-103 Magdalen Street, Norwich, NR3 1LN UK
| | - Neil Shah
- Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH UK
| | - Anna Nowak-Węgrzyn
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Tong-Xin Chen
- Department of Allergy and Immunology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127 China
| | - David M. Fleischer
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children’s Hospital Colorado , Box B518, 13123 East 16th Avenue, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Ralf G. Heine
- Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute, Parkville, VIC 3052 Australia
| | - Michael Levin
- Division of Paediatric Allergy and Asthma, Red Cross War Memorial Children’s Hospital, University of Cape Town, Room 516, ICH Building, Cape Town, South Africa
| | - Mario C. Vieira
- Centro de Gastroenterologica Pediatrica, Department of Paediatrics, Hospital Pequeno Principe, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Adam T. Fox
- Department of Paediatric Allergy, Guys and St Thomas’ Hospitals NHS Foundation Trust, London, UK
- Division of Asthma, Allergy and Lung Biology, King’s College, London, London, UK
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