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Vasconcelos PDSP, Andrade ALMB, Sandy NS, Barreto JCC, Gomez GS, Riccetto AGL, Lomazi EA, Bellomo-Brandão MÂ. Outcomes and factors associated with tolerance in infants with non-IgE-mediated cow's milk allergy with gastrointestinal manifestations. J Pediatr (Rio J) 2024; 100:40-45. [PMID: 37696495 PMCID: PMC10751709 DOI: 10.1016/j.jped.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVES To evaluate outcomes of oral food challenge (OFC) test to assess tolerance in infants with non-IgE-mediated cow's milk allergy (CMA) with gastrointestinal manifestations and explore clinical data predictive of these outcomes. METHODS Single-center retrospective study including infants (age < 12 months) who were referred for CMA between 2000 and 2018 and underwent OFC on follow-up. A univariate logistic regression test was performed to evaluate variables associated with the outcomes of the follow-up OFC test. RESULTS Eighty-two patients were included, 50% were male. Eighteen patients had a positive OFC test (22%). Most patients had presented with hematochezia (77%). The median age of symptom onset was 30 days. Two-thirds of the patients were on appropriate infant formula (extensively hydrolyzed or amino acid-based formula), exclusively or in association with breastfeeding. The median time on an elimination diet before the OFC test was 8 months (Q1 6 - Q3 11 months). All cases with positive follow-up OFC tests (n = 18) had been exposed to cow's milk-based formula before the first clinical manifestation of CMA. Five out of eight cases with Food Protein-Induced Enterocolitis Syndrome (FPIES) had positive OFC tests. Exposure to cow's milk-based formula before diagnosis, a history of other food allergies, hematochezia and diarrhea were predictors of a positive OFC test. CONCLUSIONS In infants with non-IgE-mediated CMPA with gastrointestinal manifestations, the use of cow's milk-based formula, a history of other food allergies, and hematochezia and diarrhea upon initial presentation were associated factors for the later achievement of tolerance.
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Affiliation(s)
- Príscila da Silva Pereira Vasconcelos
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | | | - Natascha Silva Sandy
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | - Juliana Corrêa Campos Barreto
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | - Gabriela Souza Gomez
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | - Adriana Gut Lopes Riccetto
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil
| | - Elizete Aparecida Lomazi
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil
| | - Maria Ângela Bellomo-Brandão
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil.
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Meyer R, Vandenplas Y, Reese I, Vieira MC, Ortiz-Piedrahita C, Walsh J, Nowak-Wegrzyn A, Chebar Lozinsky A, Fox A, Chakravarti V, Netting M, Lange L, Venter C. The role of online symptom questionnaires to support the diagnosis of cow's milk allergy in children for healthcare professionals - A Delphi consensus study. Pediatr Allergy Immunol 2023; 34:e13975. [PMID: 37366210 DOI: 10.1111/pai.13975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/11/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Cow's milk allergy (CMA) is one of the most common food allergies world-wide. The emergence of online CMA symptom questionnaires, aimed at parents and/or healthcare professionals (HCP), may raise awareness about the possible diagnosis of CMA, but also increases the risk for overdiagnosis leading to unnecessary dietary restriction impacting on growth and nutrition. This publication sets out to establish the availability of these CMA symptom questionnaires and critically assesses the development and validity. METHODS Thirteen HCP working in the field of CMA, from different countries, were recruited to participate. A combination of a Pubmed and CINAHL literature and online review using the Google search engine in English language was used. Symptoms in the questionnaires were assessed, using the European Academy for Allergy and Clinical Immunology guidelines for food allergy. Following the assessment of both the questionnaires and literature, the authors followed the modified Delphi approach to generate consensus statements. RESULTS Six hundred and fifty-one publications were identified, of which 29 were suitable for inclusion, with 26 being associated with the Cow's Milk-Related Symptoms Score. The online search yielded 10 available questionnaires: 7/10 were sponsored by formula milk companies and 7/10 were aimed at parents and three at HCP. Following the assessment of data, 19 statements were generated in two rounds of anonymous voting reaching 100% agreement. CONCLUSIONS Online CMA questionnaires, available to parents and HCP's, are varied in symptoms, and most were not validated. The overarching consensus generated from authors is that these questionnaires should not be used without the involvement of HCP.
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Affiliation(s)
- Rosan Meyer
- Department of Medicine, Imperial College London, London, UK
- Department of Nutrition and Dietetics, University of Winchester, Winchester, UK
- Department of Medicine, KU Leuven, Leuven, Belgium
| | - Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | | | - Mario C Vieira
- Center for Paediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | | | | | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
- Department of Paediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | | | - Adam Fox
- Department of Paediatric Allergy, Evelina London Children's Hospital, London, UK
| | - Vijay Chakravarti
- Paediatrics & Allergy, Ramsay Rivers & Plymouth Nuffield Hospitals, Sawbridgeworth, UK
| | - Merryn Netting
- Discipline of Pediatrics, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- SAHMRI Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Nutrition Department, Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Lars Lange
- Department of Pediatrics, GFO-Kliniken Bonn, St. Marien-Hospital, Bonn, Germany
| | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
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Oral Immunotherapy for Children with Cow's Milk Allergy: A Practical Approach. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121872. [PMID: 36553316 PMCID: PMC9777117 DOI: 10.3390/children9121872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
Cow milk allergy (CMA) is a prevalent disease in childhood. Natural history is usually favorable as CMA can disappear by school age in many subjects. Diagnosis corresponds to treatment, as an elimination diet is a solution. However, cow's milk (CM) is real food, hardly replaceable. Thus, CM reintroduction represents a demanding challenge in clinical practice. The induction of CM tolerance could be achievable using oral immunotherapy (OIT), such as the administration of increasing milk quantities until reaching tolerance. However, the OIT schedule and procedure need to be better standardized, and performance may vary widely. Therefore, the present study reports the practical experience of a third-level pediatric allergy center in managing children with CMA and submitting them to OIT. OFC and OIT are relatively safe procedures as the reaction rate is low. Almost two-thirds of the OIT subjects tolerated CM. Reactions were associated with high IgE levels. Therefore, the present experience, developed by a qualified center, may suggest and propose a practical approach for managing children with CMA. After the initial workup, including a thorough history, physical examination, and laboratory tests, OFC and, when indicated, OIT could be performed in most children with CMA.
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Al-Beltagi M, Saeed NK, Bediwy AS, Elbeltagi R. Cow’s milk-induced gastrointestinal disorders: From infancy to adulthood. World J Clin Pediatr 2022; 11:437-454. [PMID: 36439902 PMCID: PMC9685681 DOI: 10.5409/wjcp.v11.i6.437] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022] Open
Abstract
Milk is related to many gastrointestinal disorders from the cradle to the grave due to the many milk ingredients that can trigger gastrointestinal discomfort and disorders. Cow’s milk protein allergy (CMPA) is the most common food allergy, especially in infancy and childhood, which may persist into adulthood. There are three main types of CMPA; immunoglobulin E (IgE)-mediated CMPA, non-IgE-mediated CMPA, and mixed type. CMPA appears before the first birthday in almost all cases. Symptoms may start even during the neonatal period and can be severe enough to simulate neonatal sepsis. CMPA (often non-IgE mediated) can present with symptoms of gastroesophageal reflux, eosinophilic esophagitis, hemorrhagic gastritis, food protein-induced protein-losing enteropathy, and food protein-induced enterocolitis syndrome. Most CMPAs are benign and outgrown during childhood. CMPA is not as common in adults as in children, but when present, it is usually severe with a protracted course. Lactose intolerance is a prevalent condition characterized by the development of many symptoms related to the consumption of foods containing lactose. Lactose intolerance has four typical types: Developmental, congenital, primary, and secondary. Lactose intolerance and CMPA may be the underlying pathophysiologic mechanisms for many functional gastrointestinal disorders in children and adults. They are also common in inflammatory bowel diseases. Milk consumption may have preventive or promoter effects on cancer development. Milk may also become a source of microbial infection in humans, causing a wide array of diseases, and may help increase the prevalence of antimicrobial resistance. This editorial summarizes the common milk-related disorders and their symptoms from childhood to adulthood.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
- Department of Pediatrics, University Medical Center, Arabian Gulf University, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Department of Pathology, Microbiology Section, Salmaniya Medical Complex, Manama 26671, Bahrain
- Department of Pathology, Microbiology Section, Royal College of Surgeons in Ireland - Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Chest Diseases, University Medical Center, Arabian Gulf University, Manama 26671, Bahrain
| | - Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
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Maeda M, Kuwabara Y, Tanaka Y, Nishikido T, Hiraguchi Y, Yamamoto-Hanada K, Okafuji I, Yamada Y, Futamura M, Ebisawa M. Is oral food challenge test useful for avoiding complete elimination of cow's milk in Japanese patients with or suspected of having IgE-dependent cow's milk allergy? Allergol Int 2022; 71:214-220. [PMID: 34593320 DOI: 10.1016/j.alit.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cow's milk, along with hen's egg, are common causes of food allergies in children worldwide. Accidental ingestion of milk is common and often induces severe allergic reactions. Oral food challenge test (OFC) is usually performed in patients with or suspected of having a food allergy. However, the evidence of whether cow's milk OFC is useful in IgE-dependent cow's milk allergy patients to avoid total elimination is not known. METHODS After setting the clinical question and outcomes, we performed a systematic review for relevant articles published from January 1, 2000 to August 31, 2019 using PubMed® and Ichushi-Web databases. Each article was then evaluated for the level of evidence. All positive results of the OFC were defined as adverse events. RESULTS Forty articles were selected in this study. Our review revealed that cow's milk OFC was able to avoid the complete elimination of cow's milk in 66% of the patients with cow's milk allergy. We also found that adverse events occurred frequently (50.5%). CONCLUSIONS This analysis supports the recommendation of conducting cow's milk OFC to avoid complete elimination of cow's milk, however the test should be conducted with careful consideration of the patient's safety. As the methods of OFC and subjects varied among the articles selected in this study, further studies are needed to obtain higher quality evidence.
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Affiliation(s)
- Mayu Maeda
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Yu Kuwabara
- Department of Pediatrics, Ehime University Graduate School of Medicine Ehime, Japan
| | - Yuya Tanaka
- Department of Allergy, Kobe Children's Hospital, Hyogo, Japan
| | - Tomoki Nishikido
- Department of Pediatrics Pulmonology and Allergy, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yukiko Hiraguchi
- Department of Pediatrics, Center of Allergy and Clinical Immunology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | | | - Ikuo Okafuji
- Department of Pediatrics, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Yoshiyuki Yamada
- Division of Allergy and Immunology, Gunma Children's Medical Center, Gunma, Japan; Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Masaki Futamura
- Division of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Motohiro Ebisawa
- Clinical Research Center for Allergology and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan.
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Vandenplas Y, Zhao ZY, Mukherjee R, Dupont C, Eigenmann P, Kuitunen M, Ribes Koninckx C, Szajewska H, von Berg A, Bajerová K, Meyer R, Salvatore S, Shamir R, Järvi A, Heine RG. Assessment of the Cow's Milk-related Symptom Score (CoMiSS) as a diagnostic tool for cow's milk protein allergy: a prospective, multicentre study in China (MOSAIC study). BMJ Open 2022; 12:e056641. [PMID: 35177461 PMCID: PMC8860045 DOI: 10.1136/bmjopen-2021-056641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The MOSAIC study aimed to evaluate if the Cow's Milk-related Symptom Score (CoMiSS) can be used as a stand-alone diagnostic tool for cow's milk protein allergy (CMPA). DESIGN Single-blinded, prospective, multicentre diagnostic accuracy study. SETTING 10 paediatric centres in China. PARTICIPANTS 300 non-breastfed infants (median age 16.1 weeks) with suspected CMPA. INTERVENTIONS After performing the baseline CoMiSS, infants commenced a cow's milk protein elimination diet with amino acid-based formula for 14 days. CoMiSS was repeated at the end of the elimination trial. Infants then underwent an open oral food challenge (OFC) with cow's milk-based formula (CMF) in hospital. Infants who did not react during the OFC also completed a 14-day home challenge with CMF. A diagnosis of CMPA was made if acute or delayed reactions were reported. PRIMARY OUTCOME MEASURES A logistic regression model for CoMiSS to predict CMPA was fitted and a receiver-operator characteristic (ROC) curve generated. An area under the curve (AUC) of ≥0.75 was deemed adequate to validate CoMiSS as a diagnostic tool (target sensitivity 80%-90% and specificity 60%-70%). RESULTS Of 254 infants who commenced the OFC, 250 completed both challenges, and a diagnosis of CMPA made in 217 (85.4%). The median baseline CoMiSS in this group fell from 8 (IQR 5-10) to 5 (IQR 3-7) at visit 2 (p<0.000000001), with a median change of -3 (IQR -6 to -1). A baseline CoMiSS of ≥12 had a low sensitivity (20.3%), but high specificity (87.9%) and high positive predictive value (91.7%) for CMPA. The ROC analysis with an AUC of 0.67 fell short of the predefined primary endpoint. CONCLUSIONS The present study did not support the use of CoMiSS as a stand-alone diagnostic tool for CMPA. Nevertheless, CoMiSS remains a clinically useful awareness tool to help identify infants with cow's milk-related symptoms. TRIAL REGISTRATION NUMBER NCT03004729; Pre-results.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel, UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Zheng-Yan Zhao
- Children's Hospital Zhejiang, University School of Medicine, Zhejiang University, Hangzhou, China
| | | | - Christophe Dupont
- Department of Paediatrics, Hôpital Necker-Enfants Malades, Paris, France
| | - Philippe Eigenmann
- Department of Infants and Adolescents, University Hospitals Geneva, Geneva, Switzerland
| | - Mikael Kuitunen
- New Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Carmen Ribes Koninckx
- Paediatric Gastroenterology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Warszawa, Poland
| | - Andrea von Berg
- Research Institute, Department of Paediatrics, Marien-Hospital Wesel, Wesel, Germany
| | - Kateřina Bajerová
- Research Institute, Department of Paediatrics, Marien-Hospital Wesel, Wesel, Germany
| | - Rosan Meyer
- Department of Paediatrics, Imperial College London, London, UK
| | - Silvia Salvatore
- Department of Paediatrics, Hospital 'F. Del Ponte', University of Insubria, Varese, Italy
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Henderson D, Murphy CA, Glynn AC, Boyle MA, McCallion N. Feeding practices and the prevalence of cow's milk protein allergy in Irish preterm infants. J Hum Nutr Diet 2021; 35:535-541. [PMID: 34904759 DOI: 10.1111/jhn.12971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/05/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND The prevalence of cow's-milk protein allergy (CMPA) is between 2% and 3% and symptoms vary depending on underlying immune mechanism at play. Breast milk is the optimal nutrition for premature infants and breast milk fortifiers (BMF) are commonly used to optimise growth and nutrition. BMF are typically derived from cow's milk and, as such, preterm infants are exposed to cow's milk in the first weeks of life. Previously, preterm infants were suspected to have a higher risk of allergen development because of early antigen exposure and increased gut permeability. The primary aim of the present study was to evaluate the prevalence of CMPA among very preterm (<32 weeks) and/or very low birth weight (VLBW) infants. The secondary aim was to describe feeding practices, specifically the breastfeeding rates and specialist, non-standard formula use in this cohort over the first 6 months of life. METHODS This was a retrospective study performed in a large tertiary maternity hospital (8500 deliveries/year and 110 very preterm infants/year) in Dublin, Ireland over a 3-year period, 2017-2020. Infants born very preterm and/or VLBW who were followed in the outpatient clinic until 6 months corrected gestational age (CGA) were included. Hospital ethical approval was obtained. RESULTS One hundred and forty-four infants were included with a median birth weight of 1338 g. No infant had a diagnosis of CMPA when leaving the neonatal intensive care unit (NICU) but, by 6 months CGA, this increased to 1.4% (n = 2). Upon discharge from the NICU, 88 infants (61%) were receiving at least some breast milk, decreasing to 13 (9.1%) at 6 months CGA. Those who were receiving exclusive breast milk at discharge were significantly more likely to still be receiving any breast milk at three (p ≤ 0.001) and 6 months ( p ≤ 0.001) CGA compared to those combined feeding or exclusively formula feeding. At 6 months CGA, 18.9% (n = 27) were attending a dietician and 31.5% (n = 45) were using specialist, non-standard infant formula. CONCLUSIONS The prevalence of CMPA in this cohort was 1.4%, which is similar to the reported prevalence of CMPA in the general paediatric population. Infants who were discharged from NICU exclusively breastfeeding were more likely to be receiving any breast milk at outpatient follow-up. This highlights the importance of on going dietetic and lactation support in the outpatient setting for this vulnerable cohort.
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Affiliation(s)
| | - Claire A Murphy
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Michael A Boyle
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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Jung WS, Kim SH, Lee H. Missed Diagnosis of Anaphylaxis in Patients With Pediatric Urticaria in the Emergency Department. Pediatr Emerg Care 2021; 37:199-203. [PMID: 30281553 DOI: 10.1097/pec.0000000000001617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES This study was to determine the characteristics of missed diagnosis of pediatric anaphylaxis that were registered as urticaria only at the emergency department (ED) by comparing those who had only urticaria symptoms with those who had both anaphylaxis and urticaria symptoms. METHODS Subjects were classified into missed anaphylaxis and urticaria group according to whether satisfied anaphylaxis diagnostic criteria or not. Anaphylaxis group, those who were initially registered as anaphylaxis with urticaria and anaphylaxis symptoms simultaneously, were further investigated. RESULTS The missed anaphylaxis group included 37 patients of 1051 pediatric urticaria patients. The anaphylaxis group included 11 patients. The time from symptom onset to ED arrival in the missed anaphylaxis group was shorter than the urticaria group. More patients in the missed anaphylaxis group had a history of past food allergy. Seafood, egg, and milk were more common causes of allergy in the missed anaphylaxis group; however, idiopathic causes were more common in the urticaria group. Symptom was more severe in the missed anaphylaxis group than the urticaria group. More treatments except antihistamine were performed at ED in the missed anaphylaxis group. Cardiovascular symptoms were more common in the anaphylaxis group than the missed anaphylaxis group. CONCLUSIONS Of all pediatric urticaria patients, 3.5% of patients were not registered as anaphylaxis although they had anaphylaxis symptoms. Missed diagnosis of anaphylaxis in pediatric urticaria patients at ED was associated with a history of past food allergy, milk, egg, and seafood as causes of allergy, treated with fluid administration, steroid, and epinephrine.
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Affiliation(s)
- Woo Sung Jung
- From the Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
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9
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Erlewyn-Lajeunesse M, Weir T, Brown L, Howells H, Rowley J, Grainger-Allen E, Powell C. Fifteen-minute consultation: The EATERS method for the diagnosis of food allergies. Arch Dis Child Educ Pract Ed 2019; 104:286-291. [PMID: 30948483 DOI: 10.1136/archdischild-2018-316397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/11/2019] [Accepted: 02/10/2019] [Indexed: 11/03/2022]
Abstract
The EATERS mnemonic is a novel method for taking an allergy focused clinical history. It provides a degree of certainty for diagnosing food allergy and can be used in both IgE and non IgE mediated reactions. EATERS will allow health care professionals to use their existing clinical skills to interpret the history of an allergic reaction, and by doing so will help to make sense of allergy test results.
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Affiliation(s)
- Mich Erlewyn-Lajeunesse
- Department of Paediatric Allergy, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Thomas Weir
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lindsay Brown
- Department of Paediatric Allergy, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Helen Howells
- Department of Paediatric Allergy, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Emma Grainger-Allen
- Department of Paediatric Allergy, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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10
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Wen Q, Liu K, Yue W, Shao S, Zhang S, Li X, Hua Z. Clinical significance of positive fecal occult blood test in neonates. Sci Rep 2019; 9:17898. [PMID: 31784639 PMCID: PMC6884454 DOI: 10.1038/s41598-019-54511-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/12/2019] [Indexed: 11/14/2022] Open
Abstract
The fecal occult blood test (FOBT) is a screening tool for hematochezia. This study aims to summarize the clinical features associated with a positive FOBT in neonates and to explore some clues for the underlying causes. Combination with other clinical information, identifying the possible etiology is more likely and could be useful for choosing an effective therapeutic strategy. The medical records of 282 neonates with positive FOBTs from January 1 to July 31, 2016, were collected and retrospectively analyzed. The total incidence rate of FOBT positivity in neonates was 6.2%. Among these patients, 71 (25.2%) neonates had false-positive FOBTs, whereas 211 (74.8%) neonates had intraintestinal sources of hematochezia. Necrotizing enterocolitis (NEC, 20.9%), structural abnormalities of gastrointestinal tract (SAGT, 12.4%), and suspected food allergy (sFA, 10.6%) were the most common causes of neonatal hematochezia. It indicated that FOBT-positive neonates with NEC were more likely to suffer due to a younger gestational age, lower birth weight, and lower weight on admission than the neonates with other conditions. The proportions of neonates with bloody stool (90.0%) and diarrhea (63.3%) in the sFA group were markedly higher than those in the other groups. However, in the SAGT group, emesis (94.3%) and abdominal distension (80.0%) were evidently higher, usually accompanied by a relatively poor response (60.0%) and weakened bowel sounds (48.6%). Furthermore, the higher incidences of poor response (72.1%), abdominal distension (71.2%), bloody stools (64.4%), and weakened bowel sounds (62.7%) were observed in the NEC group. Due to the complicated etiology associated with a positive FOBT, the analyzed indexes were combined with other clinical features to identify the likely causes of neonatal hematochezia. Because NEC, sFA and SAGT show similar clinical manifestations and can occasionally transform into each other, close and frequent observation is crucial for timely intervention to achieve a better prognosis. Although it failed to provide an early warning of severe disease through FOBT, and the early intervention for FOBT might not decrease NEC, sFA, structural bowel injuries, or any other complications, newborn FOBT positive reminds medical staff to be alert to the related diseases including NEC, SAGT and sFA, by closer observation and follow-up.
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Affiliation(s)
- Qiuping Wen
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.,Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, P.R. China
| | - Kaizhen Liu
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.,Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, P.R. China
| | - Weihong Yue
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shiqi Shao
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shu Zhang
- Scientific Research Office, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiaoqing Li
- Department of Gastrointestinal Surgery and Neonatal Surgery, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ziyu Hua
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China. .,Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, P.R. China.
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11
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Xinias I, Cassimos D, Trypsianis G, Nivatsi M, Mavroudi A. Immediate vs delayed cow's milk protein allergy in terms of tolerance at year 1. Ann Allergy Asthma Immunol 2019; 123:304-306. [PMID: 31279074 DOI: 10.1016/j.anai.2019.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/25/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Ioannis Xinias
- 3(rd) Paediatric Department, Aristotle University of Thessaloniki, Greece
| | | | | | - Maria Nivatsi
- 1(st) Paediatric Department, Aristotle University of Thessaloniki, Greece
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12
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Micronutrient Status and Nutritional Intake in 0- to 2-Year-old Children Consuming a Cows' Milk Exclusion Diet. J Pediatr Gastroenterol Nutr 2018; 66:831-837. [PMID: 29481443 PMCID: PMC5916487 DOI: 10.1097/mpg.0000000000001942] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To study micronutrient status and nutritional intake from complementary feeding in children on a cows' milk exclusion (CME) diet. METHODS Fifty-seven children with cows' milk allergy, younger than 2 years, were included in a cross-sectional study. Blood was analyzed for micronutrient status. Complementary feeding was defined as all solids and liquids except of breast milk, and assessed by 3-day food diary. The results were analyzed according to 3 feeding patterns: mainly breast-fed (mBF), partially breast-fed, and no breast milk group (nBM). RESULTS The children had a median age of 9 months and micronutrient status was within normal range for total homocysteine (p-tHcy), s-B12, s-folate, b-Hb, s-ferritin, s-zinc, and s-25(OH)D. There were no significant differences between feedings groups, except for B12-biomarkers. The mBF had higher p-tHcy (P < 0.000) and lower s-B12 (P = 0.002) compared nBM. Vitamin B12 deficiency (p-tHcy >6.5 μmol/L combined with s-B12 <250 pmol/L) was found in 12% of participants, most frequently among the mBF (36%) and none in nBM group (P = 0.009). Vitamin B12 intake from complementary feeding was negatively correlated with p-tHcy (r = -0.479, P = 0.001) and positively with s-B12 (r = 0.410, P = 0.003). Iron deficiency anemia was found in 5%. Iron intake correlated positively with b-Hb (r = 0.324, P = 0.02). Zinc deficiency was found in 7% and low 25(OH)D in 9%. Vitamin D intake was positively correlated with the use of supplements (r = 0.456, P = 0.001). CONCLUSION The risk of B12 deficiency was high in mBF infants on CME diet, and complementary feeding was associated with better B12 status. Iron, zinc, and vitamin D deficiencies were present in all feeding groups. Complementary feeding should be introduced at 4 to 6 months of age. Vitamin D supplement is recommended to ensure adequate intake.
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Rahmoun N, El Mecherfi KE, Bouchetara A, Lardjem Hetraf S, Dahmani Amira C, Adda Neggaz L, Boudjema A, Zemani-Fodil F, Kheroua O. Association of REL Polymorphism with Cow's Milk Proteins Allergy in Pediatric Algerian Population. Fetal Pediatr Pathol 2018; 37:74-83. [PMID: 29336650 DOI: 10.1080/15513815.2017.1405468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Cow's milk proteins allergy (CMPA) pathogenesis involves complex immunological mechanisms with the participation of several cells and molecules involved in food allergy. The association of polymorphisms in the interleukin 4, Forkhead box P3 and the avian reticuloendotheliosis genes was investigated in an infant population with CMPA of Western Algeria. MATERIALS AND METHODS We obtained DNA and clinical data from milk allergic subjects during active phase and from a group of non-atopic control subjects. RESULTS Our findings showed that the allele G of the cRel gene intronic polymorphism at +7883 positions was significantly higher among cow's milk proteins allergic patients compared to control subjects. CONCLUSION The results of this study suggest a possible association of CMPA with cRel G+7883T polymorphism.
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Affiliation(s)
- Nesrine Rahmoun
- a Laboratoire de Génétique Moléculaire et Cellulaire , Université des Sciences et de la Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie.,b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie
| | - Kamel Eddine El Mecherfi
- b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie.,c Laboratoire de Physiologie de la Nutrition et Sécurité Alimentaire, Universitéd'Oran 1 Ahmed Benbella , Oran , Algérie
| | - Assia Bouchetara
- d Departement des maladies infectieuses, EHS Boukhroufa Abdelkader, Canastel , Oran , Algérie
| | - Sara Lardjem Hetraf
- a Laboratoire de Génétique Moléculaire et Cellulaire , Université des Sciences et de la Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie.,b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie
| | - Chahinez Dahmani Amira
- a Laboratoire de Génétique Moléculaire et Cellulaire , Université des Sciences et de la Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie.,b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie
| | - Leila Adda Neggaz
- b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie
| | - Abdallah Boudjema
- a Laboratoire de Génétique Moléculaire et Cellulaire , Université des Sciences et de la Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie.,b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie
| | - Faouzia Zemani-Fodil
- a Laboratoire de Génétique Moléculaire et Cellulaire , Université des Sciences et de la Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie.,b Département de génétique moléculaire appliquée , Faculté des Sciences et de la vie, Université des Sciences et de a Technologie d'Oran-Mohamed Boudiaf -USTOMB- , Oran , Algérie
| | - Omar Kheroua
- c Laboratoire de Physiologie de la Nutrition et Sécurité Alimentaire, Universitéd'Oran 1 Ahmed Benbella , Oran , Algérie
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Feng BW, Fu SM, Zhang QS, Long XL, Xie XL, Ren W, Liang ZT, Yang ZL, Chen A. [Influence of cow's milk protein allergy on the diagnosis of functional gastrointestinal diseases based on the Rome IV standard in infants and young children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:56-59. [PMID: 29335084 PMCID: PMC7390314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/23/2017] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To study the influence of cow's milk protein allergy (CMPA) on the diagnosis of functional gastrointestinal diseases (FGID) based on the Rome IV standard in infants and young children. METHODS A total of 84 children aged 1 month to 3 years who were diagnosed with CMPA were enrolled as the case group, and 84 infants and young children who underwent physical examination and had no CMPA were enrolled as the control group. The pediatricians specializing in gastroenterology asked parents using a questionnaire for the diagnosis of FGID based on the Rome IV standard to assess clinical symptoms and to diagnose FGID. RESULTS The case group had a significantly higher incidence rate of a family history of allergies than the control group (P<0.05). In the case group, 38 (45%) met the Rome IV standard for the diagnosis of FGID, while in the control group, 13 (15%) met this standard (P<0.05). According to the Rome IV standard for FGID, the case group had significantly higher diagnostic rates of reflex, functional diarrhea, difficult defecation, and functional constipation than the control group (P<0.05). The children who were diagnosed with FIGD in the control group were given conventional treatment, and those in the case group were asked to avoid the intake of cow's milk protein in addition to the conventional treatment. After 3 months of treatment, the case group had a significantly higher response rate to the treatment than the control group (P<0.05). CONCLUSIONS In infants and young children, CMPA has great influence on the diagnosis of FGID based on the Rome IV standard. The possibility of CMPA should be considered during the diagnosis of FGID.
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Affiliation(s)
- Bo-Wen Feng
- Third Clinical Medical School of Southern Medical University, Zhongshan, Guangdong 528400, China.
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15
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Onizawa Y, Noguchi E, Okada M, Sumazaki R, Hayashi D. The Association of the Delayed Introduction of Cow's Milk with IgE-Mediated Cow's Milk Allergies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:481-488.e2. [PMID: 27157937 DOI: 10.1016/j.jaip.2016.01.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/29/2015] [Accepted: 01/21/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although exclusive breastfeeding at least 4 to 6 months has been recommended to prevent IgE-mediated cow's milk allergy (IgE-CMA), early introduction of food allergens has received a lot of attention in recent years for the prevention of food allergies. OBJECTIVES We aimed to determine whether IgE-CMA is associated with a feeding pattern in early infancy. METHODS In a case-control study, we retrospectively compared the patient background, past history of atopic dermatitis, bronchial asthma, family history of allergic diseases, feeding patterns in early infancy, and the reason for choosing early infancy feeding patterns of patients with IgE-CMA with age- and sex-matched healthy controls using a questionnaire completed by their mothers. To minimize the influence of confounders, we also compared patients with IgE-CMA with those with IgE-mediated egg allergy (IgE-EA). RESULTS A total of 51 patients with IgE-CMA were compared with 102 controls (1:2 matching) and 32 unmatched patients with IgE-EA. In a multivariable logistic regression analysis, the adjusted odds ratio of delayed (started more than 1 month after birth) or no regular cow's milk formula (less than once daily) was 23.74 (95% CI, 5.39-104.52) comparing the CMA group with the Control group, and 10.16 (95% CI, 2.48-41.64) comparing the CMA group with the EA group. Only 3 (6.5%), 2 (4.8%), and 3 (14.3%) mothers in the CMA group, the Control group, and the EA group chose "To prevent allergic disease" as a reason for choosing exclusive or almost exclusive breastfeeding in the first month of life, respectively. CONCLUSIONS The early introduction of cow's milk formula is associated with lower incidence of IgE-CMA.
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Affiliation(s)
- Yutaro Onizawa
- Department of Pediatrics, Ryugasaki Saiseikai Hospital, Ibaraki, Japan
| | - Emiko Noguchi
- Department of Medical Genetics, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Masafumi Okada
- Department of Epidemiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Ryo Sumazaki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Daisuke Hayashi
- Department of Pediatrics, Ryugasaki Saiseikai Hospital, Ibaraki, Japan
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16
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Schoemaker AA, Sprikkelman AB, Grimshaw KE, Roberts G, Grabenhenrich L, Rosenfeld L, Siegert S, Dubakiene R, Rudzeviciene O, Reche M, Fiandor A, Papadopoulos NG, Malamitsi-Puchner A, Fiocchi A, Dahdah L, Sigurdardottir ST, Clausen M, Stańczyk-Przyłuska A, Zeman K, Mills ENC, McBride D, Keil T, Beyer K. Incidence and natural history of challenge-proven cow's milk allergy in European children--EuroPrevall birth cohort. Allergy 2015; 70:963-72. [PMID: 25864712 DOI: 10.1111/all.12630] [Citation(s) in RCA: 285] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cow's milk allergy (CMA) is one of the most commonly reported childhood food problems. Community-based incidence and prevalence estimates vary widely, due to possible misinterpretations of presumed reactions to milk and differences in study design, particularly diagnostic criteria. METHODS Children from the EuroPrevall birth cohort in 9 European countries with symptoms possibly related to CMA were invited for clinical evaluation including cows' milk-specific IgE antibodies (IgE), skin prick test (SPT) reactivity and double-blind, placebo-controlled food challenge. RESULTS Across Europe, 12 049 children were enrolled, and 9336 (77.5%) were followed up to 2 years of age. CMA was suspected in 358 children and confirmed in 55 resulting in an overall incidence of challenge-proven CMA of 0.54% (95% CI 0.41-0.70). National incidences ranged from 1% (in the Netherlands and UK) to <0.3% (in Lithuania, Germany and Greece). Of all children with CMA, 23.6% had no cow's milk-specific IgE in serum, especially those from UK, the Netherlands, Poland and Italy. Of children with CMA who were re-evaluated one year after diagnosis, 69% (22/32) tolerated cow's milk, including all children with non-IgE-associated CMA and 57% of those children with IgE-associated CMA. CONCLUSIONS This unique pan-European birth cohort study using the gold standard diagnostic procedure for food allergies confirmed challenge-proven CMA in <1% of children up to age 2. Affected infants without detectable specific antibodies to cow's milk were very likely to tolerate cow's milk one year after diagnosis, whereas only half of those with specific antibodies in serum 'outgrew' their disease so soon.
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Affiliation(s)
- A. A. Schoemaker
- Department of Pediatric Respiratory Medicine and Allergy; Emma Children's Hospital; Academic Medical Centre; Amsterdam The Netherlands
| | - A. B. Sprikkelman
- Department of Pediatric Respiratory Medicine and Allergy; Emma Children's Hospital; Academic Medical Centre; Amsterdam The Netherlands
| | - K. E. Grimshaw
- Clinical and Experimental Sciences Academic Unit; Faculty of Medicine; University of Southampton; Southampton UK
| | - G. Roberts
- Clinical and Experimental Sciences Academic Unit; Faculty of Medicine; University of Southampton; Southampton UK
- NIHR Respiratory Biomedical Research Unit; University Hospital Southampton NHS Foundation Trust; Southampton UK
| | - L. Grabenhenrich
- Institute of Social Medicine; Epidemiology and Health Economics; Charité University Medical Centre; Berlin Germany
| | - L. Rosenfeld
- Department of Paediatric Pneumology and Immunology; Charité University Medical Centre; Berlin Germany
| | - S. Siegert
- Department of Paediatric Pneumology and Immunology; Charité University Medical Centre; Berlin Germany
- German Agency for Quality in Medicine; Berlin Germany
| | - R. Dubakiene
- Faculty of Medicine; Vilnius University; Vilnius Lithuania
| | | | - M. Reche
- Sofia Children's University Hospital; Madrid Spain
| | - A. Fiandor
- University Hospital La Paz; Madrid Spain
| | - N. G. Papadopoulos
- Department of Allergy; Second Paediatric Clinic; University of Athens; Athens Greece
| | - A. Malamitsi-Puchner
- Neonatal Division; Second Department of Obstetrics and Gynaecology; University of Athens; Athens Greece
| | - A. Fiocchi
- Division of Allergy; Department of Pediatrics; Pediatric Hospital Bambino Gesù; Rome Italy
| | - L. Dahdah
- Division of Allergy; Department of Pediatrics; Pediatric Hospital Bambino Gesù; Rome Italy
| | - S. Th. Sigurdardottir
- Department of Immunology; Landspitali-The National University Hospital of Iceland; Reykjavik Iceland
| | - M. Clausen
- Children's Hospital; Landspitali-The National University Hospital of Iceland; Reykjavik Iceland
| | - A. Stańczyk-Przyłuska
- Department of Pediatrics, Preventive Cardiology and Immunology; Medical University of Łódź; Łódź Poland
| | - K. Zeman
- Department of Pediatrics, Preventive Cardiology and Immunology; Medical University of Łódź; Łódź Poland
- Department of Pediatrics, Immunology and Nephrology; Department of Pediatrics, Clinical Immunology and Cardiology; Polish Mother's Health Centre Research Institute Łódź; Medical University of Łódź; Łódź Poland
| | - E. N. C. Mills
- Institute of Inflammation and Repair; Manchester Academic Health Science Centre; Manchester Institute of Biotechnology; University of Manchester; Manchester UK
| | - D. McBride
- Institute of Social Medicine; Epidemiology and Health Economics; Charité University Medical Centre; Berlin Germany
| | - T. Keil
- Institute of Social Medicine; Epidemiology and Health Economics; Charité University Medical Centre; Berlin Germany
- Institute of Clinical Epidemiology and Biometry; University of Würzburg; Würzburg Germany
| | - K. Beyer
- Department of Paediatric Pneumology and Immunology; Charité University Medical Centre; Berlin Germany
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Tekgündüz KŞ, Demirelli Y, Caner İ. Cow's Milk Allergy in Preterm Infant with Bronchopulmonary Dysplasia. Turk Thorac J 2015; 16:151-153. [PMID: 29404094 DOI: 10.5152/ttd.2014.4124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 05/08/2014] [Indexed: 11/22/2022]
Abstract
Cow's milk allergy is frequent in the first year of life. The symptoms may start during the first weeks of life, and may be cutaneous (50-60%), gastrointestinal (50-60%) or respiratory (20-30%), often involving more than one organ system. In this report, we describe a case of cow's milk allergy in a preterm infant in whom rectal bleeding and respiratory symptoms resolved with the introduction of an extensively hydrolyzed formula. Occurrence of the respiratory symptoms of this disorder in a preterm infant with bronchopulmonary dysplasia may cause re-hospitalization after discharge.
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Affiliation(s)
- Kadir Şerafettin Tekgündüz
- Department of Pediatrics, Division of Neonatology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - Yaşar Demirelli
- Department of Pediatrics, Division of Neonatology, Atatürk University Faculty of Medicine, Erzurum, Turkey
| | - İbrahim Caner
- Department of Pediatrics, Division of Neonatology, Atatürk University Faculty of Medicine, Erzurum, Turkey
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Luyt D, Ball H, Makwana N, Green MR, Bravin K, Nasser SM, Clark AT. BSACI guideline for the diagnosis and management of cow's milk allergy. Clin Exp Allergy 2014; 44:642-72. [PMID: 24588904 DOI: 10.1111/cea.12302] [Citation(s) in RCA: 218] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 02/19/2014] [Accepted: 02/26/2014] [Indexed: 12/20/2022]
Abstract
This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.
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Affiliation(s)
- D Luyt
- University Hospitals of Leicester NHS Trust, Leicester, UK
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Falsaperla R, Pavone P, Miceli Sopo S, Mahmood F, Scalia F, Corsello G, Lubrano R, Vitaliti G. Epileptic seizures as a manifestation of cow's milk allergy: a studied relationship and description of our pediatric experience. Expert Rev Clin Immunol 2014; 10:1597-609. [PMID: 25394911 DOI: 10.1586/1744666x.2014.977259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Adverse reactions after ingestion of cow's milk proteins can occur at any age, from birth and even amongst exclusively breast-fed infants, although not all of these are hypersensitivity reactions. The most common presentations related to cow's milk protein allergy are skin reactions, failure to thrive, anaphylaxis as well as gastrointestinal and respiratory disorders. In addition, several cases of cow's milk protein allergy in the literature have documented neurological involvement, manifesting with convulsive seizures in children. This may be due to CNS spread of a peripheral inflammatory response. Furthermore, there is evidence that pro-inflammatory cytokines are responsible for disrupting the blood-brain barrier, causing focal CNS inflammation thereby triggering seizures, although further studies are needed to clarify the pathogenic relationship between atopy and its neurological manifestations. This review aims to analyze current published data on the link between cow's milk protein allergy and epileptic events, highlighting scientific evidence for any potential pathogenic mechanism and describing our clinical experience in pediatrics.
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Affiliation(s)
- Raffaele Falsaperla
- Paediatric Acute and Emergency Department and Operative Unit, Policlinico-Vittorio Emanuele University Hospital, University of Catania, Via Plebiscito n. 628, 95100, Catania, Italy
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Diamanti A, Fiocchi AG, Capriati T, Panetta F, Pucci N, Bellucci F, Torre G. Cow’s milk allergy and neonatal short bowel syndrome: comorbidity or true association? Eur J Clin Nutr 2014; 69:102-6. [DOI: 10.1038/ejcn.2014.156] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 06/23/2014] [Accepted: 07/02/2014] [Indexed: 01/11/2023]
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Cingolani A, Di Pillo S, Cerasa M, Rapino D, Consilvio NP, Attanasi M, Scaparrotta A, Marcovecchio ML, Mohn A, Chiarelli F. Usefulness of nBos d 4, 5 and nBos d 8 Specific IgE Antibodies in Cow's Milk Allergic Children. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2013; 6:121-5. [PMID: 24587947 PMCID: PMC3936039 DOI: 10.4168/aair.2014.6.2.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 06/13/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of study was to assess the value of recombinants in predicting the degree of symptoms in children with and without anaphylaxis to cow's milk. METHODS The study included 79 children (70±40 months) referred to the Allergological Unit of the Pediatric Department between the years 2008-2012. Group A was composed of 17 children (78±49.6 months) with anaphylaxis after ingestion of milk. Group B was composed of 62 children (73.1±38.6 months) without a history of anaphylaxis, but with less severe symptoms (gastrointestinal and/or skin symptoms). All patients from Group B had a positive open challenge with cow's milk. All patients underwent an allergic evaluation and blood samples were collected to test for IgE to recombinans of milk (nBos d 4, 5, 8). RESULTS A significant difference in nBos d 8 emerged with higher levels in Group A (median [IQR]=2.80 [0.91-16.1]) than B (0.65 [0.24-1.67]; P=0.006), whereas there were no statistically significant differences for nBos d 4 and 5. The recombinants' sum was higher in Group A than B: 8.39 [2.72-41.39] vs 3.04 [1.85-7.31] kUA/L; P=0.044. The recombinant nBos d 8 was superior to the other recombinants in identifying children at risk for anaphylaxis, with an area under the curve of 0.718 (95% CI, 0.57-0.86, P=0.006). Considering a cutoff of 1.8 kUA/L, nBos d 8 had the most favorable sensitivity and specificity ratio (sensitivity=0.65, specificity=0.77) with an odd ratio of 6.02 (95% C.I: 1.89-19.23). CONCLUSIONS This study suggested 2 phenotypes of allergic children, "high-anaphylaxis-risk" and "milder-risk". These types can be differentiated through measuring the level of IgE to nBos d 8.
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Affiliation(s)
- Anna Cingolani
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Marzia Cerasa
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Daniele Rapino
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Marina Attanasi
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | | | - Angelika Mohn
- Department of Pediatrics, University of Chieti, Chieti, Italy
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The management of paediatric allergy: not everybody's cup of tea--10-11th February 2012. Curr Opin Allergy Clin Immunol 2013; 13 Suppl 1:S1-50. [PMID: 23377496 DOI: 10.1097/aci.0b013e32835e8b94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
The age at which the majority of children outgrow cow's milk allergy now appears to be later than previously reported. Recent studies have attempted to elucidate factors that may help prevent cow's milk allergy, assess markers of persistence, and evaluate the usefulness of new diagnostic methods. Strict avoidance of cow's milk has been the mainstay of treatment. However, given the potential nutritional, social, and immunologic ramifications of cow's milk elimination from a child's diet, there has been a focus on reevaluating this therapeutic approach.
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Miyazawa T, Itabashi K, Imai T. Retrospective multicenter survey on food-related symptoms suggestive of cow's milk allergy in NICU neonates. Allergol Int 2013; 62:85-90. [PMID: 23093791 DOI: 10.2332/allergolint.11-oa-0417] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Accepted: 06/17/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cow's milk allergy (CMA) is one of the causes of gastrointestinal symptoms in neonates. A relationship between non-immunoglobulin (Ig) E mediated allergic reactions and CMA in early infancy has been proposed, but the clinical features and pathogenesis have not been established. The objective of this study is to determine the clinical characteristics of the neonates found in the earlier study to have food-related symptoms that suggested CMA. METHODS A second questionnaire was sent to 53 NICUs, as a follow-up to the earlier study, to collect information on the background, onset age, clinical features, and results of clinical examinations. RESULTS The median birth weight was 2614g and the median gestational age was 36.9 weeks. Symptoms developed within 6 days after birth in 40% of cases. Gastrointestinal symptoms were seen in 90% of cases and were mainly vomiting, bloody stool and abdominal distention. A specific IgE test, a lymphocyte stimulation test, and a fecal eosinophil test were conducted in 88%, 23% and 55% of cases, respectively, and the positive rates were 30%, 84%, and 75%, respectively. An oral food challenge (OFC) test was performed in 26% for confirmation of the diagnosis. CONCLUSIONS We confirmed that the clinical manifestations of food-related symptoms suggestive of CMA in neonates were distinctly different from those of common immediate type food allergy and were largely affected by underlying factors such as prematurity and gastroenterological surgery. Further OFC-based prospective accumulation of cases of CMA in neonates will be particularly important to reveal the full clinical features of this disease.
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Affiliation(s)
- Tokuo Miyazawa
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan. −u.ac.jp
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Allergic colitis in infants related to cow's milk: clinical characteristics, pathologic changes, and immunologic findings. Pediatr Neonatol 2013; 54:49-55. [PMID: 23445743 DOI: 10.1016/j.pedneo.2012.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 01/19/2012] [Accepted: 06/05/2012] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Allergic colitis (AC) is an inflammatory condition characterized by eosinophils infiltrating the colonic wall. It can be a benign and/or severe illness among gastrointestinal diseases in infants. METHODS We report five infants who, since January 2009, in whom AC under fibrotic endoscopic examinations has been diagnosed. The criterion for histopathologic diagnosis of AC in this study was five or more eosinophils per high-power field. Patients' clinical symptoms, pathologic findings, and immunologic studies, such as specific antibodies against component of cow's milk protein, were compared with those of allergic children without AC and those of nonatopic control children. RESULTS Histopathologic examinations of biopsy specimens revealed acute inflammation with characteristic eosinophilic infiltration of lamina propria (5-15 eosinophils per high-power field) in all five patients. They all had strongly positive skin prick tests against milk protein, which were not correlated with in vitro allergen-specific immunoglobulin (Ig) E levels. In contrast, there were significantly higher levels of IgE antibodies, and lower specific IgG4 and IgA levels to components and whole milk proteins in AC, as compared to control children without AC. CONCLUSION Endoscopic biopsy specimens of intestine confirm the diagnosis of AC. However, allergen skin prick test and IgE antibody to milk protein components also provide helpful diagnostic tools for this rare disease in children.
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Matsuki T, Kaga A, Kanda S, Suzuki Y, Tanabu M, Sawa N. Intestinal malrotation with suspected cow's milk allergy: a case report. BMC Res Notes 2012; 5:481. [PMID: 22943656 PMCID: PMC3490812 DOI: 10.1186/1756-0500-5-481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 09/01/2012] [Indexed: 01/01/2023] Open
Abstract
Background Intestinal malrotation is an incomplete rotation of the intestine. Failure to rotate leads to abnormalities in intestinal positioning and attachment that leave obstructing bands across the duodenum and a narrow pedicle for the midgut loop, thus making it susceptible to volvulus. One of the important differential diagnoses for malrotation is an allergy to cow’s milk. Several studies have described infants with surgical gastrointestinal diseases and cow’s milk allergy. However, to our knowledge, no study has reported infants with intestinal malrotation who have been symptomatic before surgery was performed and have been examined by allergen-specific lymphocyte stimulation test and food challenge tests with long-term follow-up. Case presentation The patient was a Japanese male born at 39 weeks of gestation. He was breast-fed and received commercial cow’s milk supplementation starting the day of birth and was admitted to our hospital at 6 days of age due to bilious vomiting. Plain abdominal radiography showed a paucity of gas in the distal bowel. Because we demonstrated malpositioning of the intestine by barium enema, we repositioned the bowel in a normal position by laparotomy. The patient was re-started on only breast milk 2 days post surgery because we suspected the presence of a cow’s milk allergy, and the results of an allergen-specific lymphocyte stimulation test showed a marked increase in lymphocyte response to kappa-casein. At 5 months of age, the patient was subjected to a cow’s milk challenge test. After the patient began feeding on cow’s milk, he had no symptoms and his laboratory investigations showed no abnormality. In addition, because the patient showed good weight gain and no symptoms with increased cow’s milk intake after discharge, we concluded that the present case was not the result of a cow’s milk allergy. At 1 year, the patient showed favorable growth and development, and serum allergy investigations revealed no reaction to cow’s milk. Conclusion When physicians encounter infants with surgical gastrointestinal disease, including intestinal malrotation, they should consider cow’s milk allergy as a differential diagnosis or complication and should utilize food challenge tests for a definitive diagnosis.
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Affiliation(s)
- Takuma Matsuki
- Department of Pediatrics, Hachinohe City Hospital, Bisyamontaira, Hachinohe, Aomori, Japan
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Elizur A, Rajuan N, Goldberg MR, Leshno M, Cohen A, Katz Y. Natural course and risk factors for persistence of IgE-mediated cow's milk allergy. J Pediatr 2012; 161:482-487.e1. [PMID: 22480700 DOI: 10.1016/j.jpeds.2012.02.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 01/27/2012] [Accepted: 02/20/2012] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe the natural course of IgE-mediated cow's milk allergy (IgE-CMA) and to determine risk factors for its persistence in a population-based cohort. STUDY DESIGN In a prospective cohort study, 54 infants with IgE-CMA were identified from a population of 13 019 children followed from birth. Diagnosis of IgE-CMA was based on history, skin prick test (SPT), and an oral food challenge (OFC) when indicated. Allergic infants were followed for 48-60 months. Families were contacted by telephone every 6 months and asked about recent exposures to milk. OFC was repeated to evaluate for recovery. Clinical characteristics, SPT, and OFC outcomes were compared between infants with persistent IgE-CMA and infants who recovered. RESULTS Thirty-one infants (57.4%) recovered from IgE-CMA during the study period. Most infants (70.9%) recovered within the first 2 years. Risk factors for persistence on multivariate analysis included a reaction to <10 mL of milk on OFC (or on first exposure as estimated by the guardian, if OFC was not performed) (P = .01), a larger wheal size on SPT (P = .014), and age of ≤30 days at time of first reaction (P = .05). CONCLUSIONS Resolution occurs in most infants with IgE-CMA. Infants reacting to <10 mL of milk or in the first month of life, and those with a larger wheal size on SPT, are at increased risk for persistence.
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Affiliation(s)
- Arnon Elizur
- Allergy and Immunology Institute, Assaf Harofeh Medical Center, Zerifin, Israel
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Zachariassen G, Faerk J, Esberg BH, Fenger-Gron J, Mortensen S, Christesen HT, Halken S. Allergic diseases among very preterm infants according to nutrition after hospital discharge. Pediatr Allergy Immunol 2011; 22:515-20. [PMID: 21332800 DOI: 10.1111/j.1399-3038.2010.01102.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To determine whether a cow's milk-based human milk fortifier (HMF) added to mother's milk while breastfeeding or a cow's milk-based preterm formula compared to exclusively mother's milk after hospital discharge, increases the incidence of developing allergic diseases among very preterm infants (VPI) during the first year of life. Of a cohort of 324 VPI (gestational age 24-32 wk), the exclusively breastfed VPI were shortly before discharge randomized to breastfeeding without fortification or supplementing with a fortifier. Those not breastfed were fed a preterm formula. The intervention period was from discharge until 4 months corrected age (CA). Follow-up was performed at 4 and 12 months CA including specific IgE to a panel of allergens at 4 months CA. The incidence during and prevalence at 12 months CA of recurrent wheezing (RW) was 39.2% and 32.7%, while atopic dermatitis (AD) was 18.0% and 12.1%, respectively. Predisposition to allergic disease increased the risk of developing AD (p=0.04) [OR 2.6 (95% CI 1.0-6.4)] and the risk of developing RW (p=0.02) [OR 2.7 (95% CI 1.2-6.3)]. Boys had an increased risk of developing RW (p=0.003) [OR 3.1 (95% CI 1.5-6.5)]. No difference was found between nutrition groups. None developed food allergy. Compared to exclusively breastfed, VPI supplemented with HMF or fed exclusively a preterm formula for 4 months did not have an increased risk of developing allergic diseases during the first year of life.
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Affiliation(s)
- Gitte Zachariassen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense C, Denmark.
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Hsu J, Brożek JL, Terracciano L, Kreis J, Compalati E, Stein AT, Fiocchi A, Schünemann HJ. Application of GRADE: making evidence-based recommendations about diagnostic tests in clinical practice guidelines. Implement Sci 2011; 6:62. [PMID: 21663655 PMCID: PMC3126717 DOI: 10.1186/1748-5908-6-62] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 06/10/2011] [Indexed: 11/10/2022] Open
Abstract
Background Accurate diagnosis is a fundamental aspect of appropriate healthcare. However, clinicians need guidance when implementing diagnostic tests given the number of tests available and resource constraints in healthcare. Practitioners of health often feel compelled to implement recommendations in guidelines, including recommendations about the use of diagnostic tests. However, the understanding about diagnostic tests by guideline panels and the methodology for developing recommendations is far from completely explored. Therefore, we evaluated the factors that guideline developers and users need to consider for the development of implementable recommendations about diagnostic tests. Methods Using a critical analysis of the process, we present the results of a case study using the Grading of Recommendations Applicability, Development and Evaluation (GRADE) approach to develop a clinical practice guideline for the diagnosis of Cow Milk Allergy with the World Allergy Organization. Results To ensure that guideline panels can develop informed recommendations about diagnostic tests, it appears that more emphasis needs to be placed on group processes, including question formulation, defining patient-important outcomes for diagnostic tests, and summarizing evidence. Explicit consideration of concepts of diagnosis from evidence-based medicine, such as pre-test probability and treatment threshold, is required to facilitate the work of a guideline panel and to formulate implementable recommendations. Discussion This case study provides useful guidance for guideline developers and clinicians about what they ought to demand from clinical practice guidelines to facilitate implementation and strengthen confidence in recommendations about diagnostic tests. Applying a structured framework like the GRADE approach with its requirement for transparency in the description of the evidence and factors that influence recommendations facilitates laying out the process and decision factors that are required for the development, interpretation, and implementation of recommendations about diagnostic tests.
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Affiliation(s)
- Jonathan Hsu
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Lee JH, Noh J, Noh G, Choi WS, Cho S, Lee SS. Allergen-specific transforming growth factor-β-producing CD19+CD5+ regulatory B-cell (Br3) responses in human late eczematous allergic reactions to cow's milk. J Interferon Cytokine Res 2011; 31:441-9. [PMID: 21291325 DOI: 10.1089/jir.2010.0020] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
CD19(+)CD5(+) regulatory B cells produce transforming growth factor β (TGF-β) in both mouse and human B-cell leukemias. In this study, TGF-β was uniquely produced by normal human regulatory B cells. TGF-β-producing regulatory B-cell (Br3) responses were characterized through allergic responses to cow's milk. In total, 10 subjects allergic to milk and 13 milk-tolerant subjects were selected following double-blinded, placebo-controlled food challenges. Their peripheral blood mononuclear cells were stimulated in vitro with casein. Following allergen stimulation, the percentage of Br3s among CD5(+) B cells decreased from 11.5% ± 13.7% to 8.0% ± 9.6% (P = 0.042, n = 5) in the milk-allergy group and increased from 14.7% ± 15.6% to 18.9% ± 20.1% (P = 0.006, n = 7) in the milk-tolerant group. However, the numbers of Br3s increased only in the milk-tolerant group, from 1,954 ± 1,058 to 4,548 ± 1,846 per well (P = 0.026), whereas the numbers of Br3s in the milk-allergy group were unchanged [2,596 ± 823 to 2,777 ± 802 per well (P = 0.734)]. The numbers of apoptotic events were similar to the numbers of total Br3 responses. The percentage of non-TGF-β-producing CD5(+) B cells with apoptotic changes increased from 13.4% ± 17.1% to 16.4% ± 20.3% (P = 0.047, n = 5) in the milk-allergy group and remained unchanged [from 9.9% ± 11.9% to 9.3% ± 11.4% (P = 0.099, n = 7)] in the milk-tolerant group. Using carboxyfluorescein succinimidyl ester labeling, we observed that the percentage of proliferating Br3s among CD5(+) B cells was unchanged [from 6.1% ± 2.8% to 6.4% ± 2.9% (P = 0.145)] in the milk-allergy group and increased from 6.8% ± 3.9% to 10.2% ± 5.3% (P = 0.024) in the milk-tolerant group. In conclusion, Br3s proliferated in response to allergen stimulation in the milk-tolerant group and not in the milk-allergy group. TGF-β-producing regulatory B cells (Br3) may be involved in allergy tolerance by negatively regulating the immune system with TGF-β, and this negative regulation may be controlled by apoptosis.
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Affiliation(s)
- Jae Ho Lee
- Department of Paediatrics, College of Medicine, Chungnam National University, Jung-gu, Daejeon, Korea
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Saps M, Lu P, Bonilla S. Cow's-milk allergy is a risk factor for the development of FGIDs in children. J Pediatr Gastroenterol Nutr 2011; 52:166-9. [PMID: 20975580 DOI: 10.1097/mpg.0b013e3181e85b55] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Functional gastrointestinal disorders (FGIDs) are common in children. Their pathogenesis remains unknown and is most likely multifactorial. We hypothesized that noninfectious causes of inflammation affecting the gastrointestinal (GI) tract early in life, such as cow's-milk allergy (CMA), can predispose to the development of FGIDs later in childhood. PATIENTS AND METHODS Case-control study. Subjects were patients between 4 and 18 years diagnosed with CMA in the first year of life at Children's Memorial Hospital in Chicago, IL, between January 2000 and June 2009. Diagnosis of CMA was based on history and clinical findings. Siblings 4 to 18 years of age without a history of CMA were selected as controls. Cases completed the parental form of the Pediatric Gastrointestinal Symptoms Rome III version questionnaire to assess for GI symptoms. RESULTS Fifty-two subjects (mean age 8.1 ± 4.48 years, 62% girls) and 53 controls (mean age 9.7 ± 4.20 years, 55% girls) participated in the study. Twenty-three of 52 subjects (44.2%) reported GI symptoms that included abdominal pain, constipation, or diarrhea compared with 11 of 53 controls (20.75%) (odds ratio 3.03, P = 0.01). Abdominal pain was significantly more common in cases (16/52, 30.8%) versus controls (5/53, 9.43%) (odds ratio 4.27 [1.43-12.7]) (χ² = 7.47, P = 0.01). Abnormal stool habits were more common in cases (15/52, 28.8%) versus controls (7/53, 13.2%), but the difference was not statistically significant. Ten of 52 subjects (19.2%) met the Questionnaire on Pediatric Gastrointestinal Symptoms Rome III version criteria for diagnosis of an FGID (7 irritable bowel syndrome, 2 functional dyspepsia, 1 functional abdominal pain), whereas none in the control group did. CONCLUSIONS CMA constitutes a risk factor for the development of FGIDs in children.
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Affiliation(s)
- Miguel Saps
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Gastrointestinal Motility and Functional Bowel Disorders Program, Children's Memorial Hospital, Northwestern University, Chicago, IL, USA.
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Morisset M, Aubert-Jacquin C, Soulaines P, Moneret-Vautrin DA, Dupont C. A non-hydrolyzed, fermented milk formula reduces digestive and respiratory events in infants at high risk of allergy. Eur J Clin Nutr 2010; 65:175-83. [DOI: 10.1038/ejcn.2010.250] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Krane Kvenshagen B, Jacobsen M, Halvorsen R. Can conjunctival provocation test facilitate the diagnosis of food allergy in children? Allergol Immunopathol (Madr) 2010; 38:321-6. [PMID: 20605314 DOI: 10.1016/j.aller.2010.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 01/11/2010] [Accepted: 01/19/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Food allergy is common in children, occurring in 5-7.5%. The diagnosis may, however, be difficult. Elevated IgE or positive skin prick test to a food allergen is often considered proof of allergy, but may represent sensitisation without clinical manifestations. For a precise diagnosis oral challenge is necessary, but this is often not performed because of risk of serious allergic reactions. The aim of this study was to evaluate whether conjunctival provocation test would facilitate the diagnosis of IgE-mediated food allergy. METHODS One hundred and forty-nine children with 174 possible diagnoses of food allergy were included. General examination, skin prick test and specific IgE were performed, as well as conjunctival provocation test of the suspected food allergen. Open food challenges and double-blind placebo controlled tests were performed in order to diagnose possible food allergy. RESULTS Forty-six children with strongly positive conjunctival reactions (rubor, itching, oedema) to fifty food allergens were all proven to have allergy to the food in question. The children with negative conjunctival provocation tests showed no allergic reactions when challenged. CONCLUSIONS We find that a strongly positive conjunctival reaction to a food allergen correlates well with true allergy. An oral challenge should be carefully performed. With a negative conjunctival test an oral challenge may safely be performed.
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Katz Y, Rajuan N, Goldberg MR, Eisenberg E, Heyman E, Cohen A, Leshno M. Early exposure to cow's milk protein is protective against IgE-mediated cow's milk protein allergy. J Allergy Clin Immunol 2010; 126:77-82.e1. [PMID: 20541249 DOI: 10.1016/j.jaci.2010.04.020] [Citation(s) in RCA: 281] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 04/21/2010] [Accepted: 04/21/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND The diversity in the perceived prevalence, recovery, and risk factors for cow's milk allergy (CMA) necessitated a large-scale, population-based prospective study. OBJECTIVE We sought to determine the prevalence, cross-reactivity with soy allergy, and risk factors for the development of CMA. METHODS In a prospective study the feeding history of 13,019 infants was obtained by means of telephone interview (95.8%) or questionnaire (4.2%). Infants with probable adverse reactions to milk were examined, skin prick tested, and challenged orally. RESULTS Ninety-eight percent of the cohort participated in the study. The cumulative incidence for IgE-mediated CMA was 0.5% (66/13,019 patients). The mean age of cow's milk protein (CMP) introduction was significantly different (P < .001) between the healthy infants (61.6 +/- 92.5 days) and those with IgE-mediated CMA (116.1 +/- 64.9 days). Only 0.05% of the infants who were started on regular CMP formula within the first 14 days versus 1.75% who were started on formula between the ages of 105 and 194 days had IgE-mediated CMA (P < .001). The odds ratio was 19.3 (95% CI, 6.0-62.1) for development of IgE-mediated CMA among infants with exposure to CMP at the age of 15 days or more (P < .001). Sixty-four patients with IgE-mediated CMA tolerated soy, and none had a proved allergy to soy. CONCLUSIONS IgE-mediated CMA is much less common than generally reported. Early exposure to CMP as a supplement to breast-feeding might promote tolerance. Finally, soy is a reasonable feeding alternative in patients with IgE-mediated CMA.
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Affiliation(s)
- Yitzhak Katz
- Allergy and Immunology Institute, Assaf-Harofeh Medical Center, Zerifin, Israel.
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Effect of feeding a formula supplemented with long-chain polyunsaturated fatty acids for 14 weeks improves the ex vivo response to a mitogen and reduces the response to a soy protein in infants at low risk for allergy. J Pediatr Gastroenterol Nutr 2010; 50:661-9. [PMID: 20386325 DOI: 10.1097/mpg.0b013e3181b99cd5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Feeding long-chain polyunsaturated fatty acids (LCP) influences immunity in adults; however, less is known about their effect during development. The aim of the study was to determine the effect of feeding LCP on immunity in healthy infants during the first 4 months of life. PATIENTS AND METHODS Formula-fed infants were randomized at <or=14 days of age to standard term formula (Formula) or formula containing LCP (Formula+LCP). Infants exclusively fed human milk (HM) were included for comparison. At 16 weeks of age, blood was collected and phenotypes, the ability to proliferate and produce cytokines (interleukin [IL]-2, IL-4, IL-6, IL-10, IL-12, interferon [IFN]-gamma, tumor necrosis factor [TNF]-alpha, TGF-beta) after incubation with phytohemaglutinin (PHA), beta-lactoglobulin, or soy protein were measured. RESULTS Feeding LCP resulted in a higher than and more similar proliferation rate to PHA in HM-fed infants, possibly because of a greater TH1 type cytokine response and a higher percentage of antigen mature (CD45RO+) cells (P < 0.05). The response to beta-lactoglobulin did not differ among groups. After incubation with soy protein Formula+LCP, compared with Formula produced less IL-2 and more TNF-alpha and had a higher percentage of CD8+ and a lower percentage of CD20+ (CD20+CD54+) cells poststimulation (P < 0.05). Both formula groups produced less IL-2 after PHA, had a lower percentage of CD80+ cells, and a higher percentage of CD54+ cells after incubation with food proteins (P < 0.05). CONCLUSIONS Formula-fed infants, at low risk for allergy, respond differently to mitogen and food proteins ex vivo than those fed HM. Feeding LCP altered some of these differences in the direction that is hypothesized to confer immune benefits.
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Noh J, Lee JH, Noh G, Bang SY, Kim HS, Choi WS, Cho S, Lee SS. Characterisation of allergen-specific responses of IL-10-producing regulatory B cells (Br1) in Cow Milk Allergy. Cell Immunol 2010; 264:143-9. [PMID: 20646682 DOI: 10.1016/j.cellimm.2010.05.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 05/10/2010] [Accepted: 05/22/2010] [Indexed: 01/04/2023]
Abstract
CD19+CD5+ regulatory B cells regulate immune responses by producing IL-10. IL-10-producing regulatory B cell (Br1) responses by allergen stimulation were investigated in human food allergy. Six milk allergy patients and eight milk-tolerant subjects were selected according to DBPCFC. PBMCs were stimulated by casein in vitro and stained for intracellular IL-10 and apoptosis. In response to allergen stimulation, Br1 decreased from 26.2+/-18.3 to 15.5+/-8.9% (p=0.031, n=6) in the milk allergy group and increased from 15.4+/-9.0 to 23.7+/-11.2% (p=0.023, n=8) in the milk-tolerant group. Apoptotic non-IL-10-producing regulatory B cells increased from 21.8+/-9.3 to 38.0+/-16.1% (p=0.031, n=6) in the milk allergy group and unchanged from 28.8+/-13.8 to 28.0+/-15.0% (p=0.844, n=8) in the milk-tolerant group. Br1 may be involved in the immune tolerance of food allergies by producing IL-10 and simultaneously undergoing apoptosis in humans. The exact roles for Br1 in immune tolerance needs to be further investigated.
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Affiliation(s)
- Joonyong Noh
- Department of Animal Biotechnology, College of Animal Bioscience and Technology, Konkuk University, Seoul, Republic of Korea
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Abstract
Atopy patch test may help early diagnosis of cow-milk allergy in preterm infants. In the retrospective analysis of 5 girls and 9 boys, born at 31 +/- 2 (mean +/- SD) weeks of gestation and presenting digestive symptoms at age 42 +/- 18 days, 10 had a complete recovery following the shift to an exclusive feeding with an amino acid-based formula. Cow-milk-skin prick tests and specific immunoglobulin E were always negative, whereas the atopy patch test was positive in 7 of the 10 infants with complete recovery.
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Fiocchi A, Brozek J, Schünemann H, Bahna SL, von Berg A, Beyer K, Bozzola M, Bradsher J, Compalati E, Ebisawa M, Guzman MA, Li H, Heine RG, Keith P, Lack G, Landi M, Martelli A, Rancé F, Sampson H, Stein A, Terracciano L, Vieths S. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. World Allergy Organ J 2010; 3:57-161. [PMID: 23268426 PMCID: PMC3488907 DOI: 10.1097/wox.0b013e3181defeb9] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Poddar U, Yachha SK, Krishnani N, Srivastava A. Cow's milk protein allergy: an entity for recognition in developing countries. J Gastroenterol Hepatol 2010; 25:178-82. [PMID: 19817954 DOI: 10.1111/j.1440-1746.2009.06017.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AIM The aim of this prospective study was to determine cow's milk protein allergy (CMPA) cases in a tertiary care hospital in India and to study its clinical presentations and outcome following treatment. METHODS Consecutive children with chronic diarrhea from June 2004 to December 2007 were evaluated with hemogram, anti-endomysial antibody, upper gastrointestinal endoscopy, sigmoidoscopy and intestinal biopsies. Initial diagnosis of CMPA was based on characteristic intestinal biopsy (> 6 eosinophils/HPF) and diagnosis was confirmed by positive milk challenge. RESULTS Forty CMPA cases (25 boys, with a mean age of 17.2 +/- 7.8 months and symptom duration of 8.3 +/- 6.2 months) presented with diarrhea (bloody in 16, watery in 16, combined in three, recurrent hematemesis in two, rectal bleeding in one and one case each with pain in the abdomen with vomiting and anemia with occult bleeding). Sigmoidoscopy revealed aphthous ulcers in 82% of cases and rectal biopsy was positive in 97% of cases. All children improved on a milk-free diet. Milk challenge was positive in 100% of cases when it was done early (within 6 months). On follow up of 15 +/- 9 months, milk was successfully restarted in 25 cases after a median milk-free period of 15 months, 10 were still on a milk-free diet and five were lost to follow up while on a milk-free diet. CONCLUSIONS CMPA is not uncommon in a developing country such as India. Presence of aphthous ulcers and abnormal rectal biopsy are clues to initial diagnosis. Milk challenge confirms the diagnosis in all if it is done on time.
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Affiliation(s)
- Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Lee JH, Noh J, Noh G, Kim HS, Mun SH, Choi WS, Cho S, Lee S. Allergen-specific B cell subset responses in cow’s milk allergy of late eczematous reactions in atopic dermatitis. Cell Immunol 2010; 262:44-51. [DOI: 10.1016/j.cellimm.2009.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 12/03/2009] [Accepted: 12/21/2009] [Indexed: 12/30/2022]
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Abstract
Food hypersensitivity (FHS) is the umbrella term used for food allergies that involve the immune system and food intolerances that do not involve the immune system. FHS has a huge impact on quality of life and any dietary advice given should aim to minimise this effect. Despite many advances made in diagnosing and managing patients with FHS, the cornerstone of management still remains avoidance of the relevant food. However, a commonly-presenting dilemma in clinical practice is deciding to what extent the food(s) should be avoided. The level of avoidance required is currently based on the type of FHS the patient has, characteristics of the particular food protein and the natural history of the particular FHS. In addition to management of other FHS, management of cow's milk allergy requires the healthcare professional to choose the appropriate formula. Information required by the patient also includes understanding food labels and issues surrounding cross-contamination. In order to ensure that the diet is nutritionally sound, advice should be given about suitable food choices and following a healthy balanced diet, whilst taking into account the dietary restrictions. Practical issues that need to be addressed include going on holiday, travelling and eating away from home. The dietitian plays a crucial role in this process. At present, there are no standardised documents or protocols for the management of FHS and practices differ within and between countries. If adrenaline auto-injectors are prescribed, correct administration should be demonstrated and reviewed on an ongoing basis.
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Vlieghe V, Des Roches A, Payot A, Lachance C, Nuyt AM. Human milk fortifier in preterm babies: source of cow's milk protein sensitization? Allergy 2009; 64:1690-1. [PMID: 19824889 DOI: 10.1111/j.1398-9995.2009.02110.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- V Vlieghe
- Research Center, CHU Ste-Justine, Department of Pediatrics, University of Montréal, 3175 Côte Sainte-Catherine, Montréal, QC H3T 1C5, Canada
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Immunologisch bedingte Nahrungsmittelunverträglichkeiten. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-2047-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Current World Literature. Curr Opin Allergy Clin Immunol 2009; 9:284-90. [DOI: 10.1097/aci.0b013e32832c00ee] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Marseglia G, Caimmi D, Caimmi S, Castellazzi A. Cow's milk allergy: how to deal with it. Allergol Immunopathol (Madr) 2009; 36:313-4. [PMID: 19150028 DOI: 10.1016/s0301-0546(08)75861-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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