1
|
Yang F, Zhou C, Li L, Wang X, Wang B, Hu Y, Zhang Y, Chen C, Li J, Yu X. A nomogram for predicting food allergy in infants with feeding problems and malnutrition. J Pediatr Gastroenterol Nutr 2024; 78:1161-1170. [PMID: 38374772 DOI: 10.1002/jpn3.12159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND OBJECTIVE As oral food challenge (OFC) cannot be performed routinely in the general outpatient, this study aimed to construct a nomogram to predict the odds of food allergy in infants with idiopathic feeding problems and malnutrition. METHODS From August 2018 to December 2021, 289 infants (median age, 6 months; P25-P75, 4-8) with idiopathic feeding problems and malnutrition were enrolled from seven hospitals in Shanghai, China. Food allergy was defined as a positive response to a skin prick test or OFC, with gastrointestinal, dermatologic, or respiratory symptom improvement after 4 weeks of avoidance of the suspected food. Demographic characteristics, Cow's Milk-related Symptom Scores (CoMiSS), and blood eosinophil amounts were evaluated for their associations with food allergy. Multivariable logistic regression analysis was used to identify variables to develop a nomogram model with the bootstrapped-concordance index as an assessment metric. RESULTS Totally 249 of 289 infants had food allergy (86.2%). After logistic regression analysis, the feeding pattern (odds ratio [OR] = 5.28, 95% confidence interval [CI]: 2.13-13.09), a family history of allergy (OR = 1.79, 95% CI: 0.71-4.51), CoMiSS (OR = 1.45, 95% CI: 1.19-1.77), and eosinophil percentage (OR = 1.33, 95% CI: 1.11-1.60) were used to develop the model, which had a good performance with an area under the curve of 0.868 (95% CI: 0.792-0.944) and a bootstrapped-concordance index of 0.868. CONCLUSION Food allergy is common in infants with idiopathic feeding problems and malnutrition. The developed nomogram may help identify infants with food allergy for further diagnosis.
Collapse
Affiliation(s)
- Fan Yang
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
| | - Chunyan Zhou
- Translational Medicine Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Luanluan Li
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
| | - Xirui Wang
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
| | - Bin Wang
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University, Shanghai, China
| | - Yabin Hu
- Department of Clinical Epidemiology and Biostatistics, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yue Zhang
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
| | - Chen Chen
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
| | - Juan Li
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
| | - Xiandan Yu
- Department of Developmental and Behavioral Pediatrics, Shanghai Jiao Tong University, Shanghai, China
- State Environmental Protection Key Laboratory of Environmental Health Impact Assessment of Emerging Contaminants, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
2
|
El-Shafie AM, Omar ZA, El Zefzaf HMS, Basma EM, Al Sabbagh NM, Bahbah WA. Evaluation of Cow's Milk Related Symptom Score [CoMiSS] accuracy in cow's milk allergy diagnosis. Pediatr Res 2023; 94:987-995. [PMID: 36871030 PMCID: PMC10444607 DOI: 10.1038/s41390-023-02539-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Cow's Milk-related Symptom Score (CoMiSS) is an awareness tool to recognize cow's milk allergy (CMA) symptoms in infants. We aimed to assess the best cut-off point of CoMiSS in our country and investigate other parameters suggested to raise the strength of CoMiSS in CMA diagnosis. METHODS We enrolled 100 infants with CMA-suggestive symptoms with documentation of CoMiSS initially and 4 weeks after cow milk-free diet (CMFD) followed by an open food challenge (OFC) test. Infants with symptom recurrence upon challenge were diagnosed with confirmed CMA. RESULTS Initial mean CoMiSS was 15.76 ± 5.29, being higher in the confirmed CMA group (84% of infants). Following CMFD, median CoMiSS significantly reduced to 1.5 in the confirmed CMA group compared to 6.5 in the negative group. Receiver operation characteristic (ROC) curve identified a CoMiSS score of ≥12 as the best cut-off value with 76.19% sensitivity, 62.50% specificity and overall accuracy of 74.00%. Mucoid stool, bloody stool and faltering growth were reported in 80, 41 and 52% of confirmed CMA infants, respectively, with considerable improvement following CMFD. CONCLUSIONS Our study revealed a CoMiSS score of ≥12 to be the best cut-off point. However, CoMiSS cannot be used alone for accurate diagnosis of CMA. IMPACT CoMiSS ≥12 can predict a positive response to CMFD; nevertheless, CoMiSS is a good awareness tool and cannot be regarded as a stand-alone CMA diagnostic test. CoMiSS reduction following CMFD was predictive of a reaction to OFC to diagnose CMA as well as for monitoring symptom improvement. Symptoms commonly associated with CMA as mucoid stool, bloody stool, marked abdominal distention not responding to medical treatment and faltering growth, in addition to their improvements in response to CMA are suggested parameters to be added to CoMiSS to improve its accuracy.
Collapse
Affiliation(s)
- Ali M El-Shafie
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Zein A Omar
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Heba M S El Zefzaf
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt.
| | - Elsayedamr M Basma
- Department of Bioinformatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Nahla M Al Sabbagh
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Wael A Bahbah
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Immunoproteomics of cow's milk allergy in Mexican pediatric patients. J Proteomics 2023; 273:104809. [PMID: 36587729 DOI: 10.1016/j.jprot.2022.104809] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/24/2022] [Accepted: 12/25/2022] [Indexed: 12/31/2022]
Abstract
Immunological mechanisms of non-IgE-mediated cow's milk protein allergy (CMPA) are not well understood. Such a circumstance requires attention with the aim of discovering new biomarkers that could lead to better diagnostic assays for early treatment. Here, we sought both to investigate the mechanism that underlies non-IgE-mediated CMPA and to identify cow's milk immunoreactive proteins in a Mexican pediatric patient group (n = 34). Hence, we determined the IgE and IgG1-4 subclass antibody levels against cow's milk proteins (CMP) by ELISA. Then, we performed 2D-Immunoblots using as first antibody immunoglobulins in the patients'serum that bound specifically against CMP together with CMP enrichment by ion-exchange chromatography. Immunoreactive proteins were identified by mass spectrometry-based proteomics. The serological test confirmed absence of specific IgE in the CMPA patients but showed significant increase in antigen-specific IgG1. Additionally, we identified 11 proteins that specifically bound to IgG1. We conclude that the detection of specific IgG1 together with an immunoproteomics approach is highly relevant to the understanding of CMPA's physiopathology and as a possible aid in making a prognosis since current evidence indicates IgG1 occurrence as an early signal of potential risk toward development of IgE-mediated food allergy. SIGNIFICANCE: Allergies are one of the most studied topics in the field of public health and novel protein allergens are found each year. Discovery of new principal and regional allergens has remarkable repercussions in precise molecular diagnostics, prognostics, and more specific immunotherapies. In this context, specific IgE is widely known to mediate physiopathology; however, allergies whose mechanism does not involve this immunoglobulin are poorly understood although their incidence has increased. Therefore, accurate diagnosis and adequate treatment are delayed with significant consequences on the health of pediatric patients. The study of type and subtypes of immunoglobulins associated with the immunoreactivity of cow's milk proteins together with an immunoproteomics approach allows better comprehension of physiopathology, brings the opportunity to discover new potential cow's milk protein allergens and may help in prognosis prediction (IgG1 occurrence as an early signal of possible risk toward development of IgE-mediated food allergy).
Collapse
|
5
|
Yin N, Liu X, Zhang X, Wen J, Ma H, Yin X, Xie C, Hou Y, Wang J. Comparison of the effects of different infant formulas on the growth and development and intestinal flora of infants. Food Sci Nutr 2023; 11:1113-1126. [PMID: 36789049 PMCID: PMC9922136 DOI: 10.1002/fsn3.3149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 11/05/2022] [Accepted: 11/06/2022] [Indexed: 12/12/2022] Open
Abstract
The purpose of this study was to compare the effects of different infant formulas on the growth and development, sleep, allergy symptoms, and intestinal flora of infants. A total of 428 infants participated in the study. Breastfeeding (BF) was used as the control, and the remaining subjects were randomly assigned to the full goat milk protein formula group (FGM), partial goat milk protein formula group (PGM), and cow milk formula group (M). During the 6-month feeding experiment, data on the growth, sleep, allergy symptoms, and intestinal flora of infants were collected using questionnaires, anthropometric measurements, and biochemical examinations. In general, the basic information of the participants was consistent among the groups. There were no differences in infant weight, length, or head circumference among the groups (p > .05). The sleep time of infants in the formula-fed groups was longer than that of the breastfeeding group at baseline (p < .05), but there were no differences at mid-term or outcome (p > .05). The incidence of allergic symptoms continued to decrease, and the total scores of allergic symptoms did not differ among the groups (p > .05). The relative abundance of intestinal Bifidobacteriaceae in the PGM group was lower than that in the other groups (p < .05). There was no difference in the β-diversity of intestinal flora between formula-fed and breastfed infants (p > .05). There were strong correlations in the composition of the main intestinal flora at the family level between the formula and breastfeeding groups. This study showed that within 6 months of feeding, there were no significant differences in the growth and development, allergic symptoms, or intestinal flora of the infants among the groups.
Collapse
Affiliation(s)
- Ning Yin
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
| | - Xinran Liu
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
| | - Xiaoxuan Zhang
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
| | - Jing Wen
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
| | - Huijuan Ma
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
| | - Xueqian Yin
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
| | | | - Yanmei Hou
- Ausnutria Hyproca Nutrition Co., Ltd.ChangshaChina
| | - Junbo Wang
- Department of Nutrition and Food Hygiene, School of Public HealthPeking UniversityBeijingChina
- Beijing Key Laboratory of Toxicological Research and Risk Assessment for Food SafetyPeking UniversityBeijingChina
| |
Collapse
|
6
|
Ursino FG, Orsi M, Mehaudy R, Micheletti ME, Parisi C, Petriz N, Parente C, Jauregui MB, Pagoto V. Cultural adaptation and validation of the Spanish version of the Cow's Milk-related Symptom Score (CoMiSS) for cow's milk protein allergy. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:44-49. [PMID: 34887216 DOI: 10.1016/j.rgmxen.2021.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/11/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS The prevalence of cow's milk protein allergy in the first year of life varies from 1.8 to 7.5%. The Cow's Milk-related Symptom Score (CoMiSS) was published in 2014 and facilitates the diagnosis of cow's milk protein allergy. It is not meant to replace the clinical diagnosis, but rather to guide the treating team in the diagnostic process and reduce unnecessary diets. The aim was to translate the CoMiSS from English to Spanish and culturally adapt and validate the resulting Spanish version. MATERIALS AND METHODS An adaptation and validation study on the CoMiSS questionnaire was carried out in two phases: First, the CoMiSS was translated from English to Spanish, after which interrater reliability of the translated score was assessed. Second, interrater reliability tests were carried out on 32 pediatric patients under 7 years of age that were treated for the first time at the Food Allergy Clinic of the Hospital Italiano de Buenos Aires, were suspected of having cow's milk protein allergy, and had not received any treatment, within the time frame of May 2018 and May 2019. RESULTS Thirty-two patients were evaluated, 14 of whom were females (45%), and the median patient age was 3 months (IQR 2-4). The median result of the first measurement of the scale was 7.0 (IQR 4.5-9.0) and the median of the second measurement was 5.0 (IQR 4.0-8.0). The final intraclass correlation coefficient was 0.80 (95% CI 0.63-0.9). CONCLUSION The Spanish translation of the CoMiSS was comparable to the original English version, with excellent interrater reliability. This simple and little-known tool has the benefit of being a noninvasive, rapid, reliable, and easy-to-use strategy.
Collapse
Affiliation(s)
- F G Ursino
- Departamento de Gastroenterología infantil, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - M Orsi
- Departamento de Gastroenterología infantil, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - R Mehaudy
- Departamento de Gastroenterología infantil, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M E Micheletti
- Departamento de Gastroenterología infantil, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - C Parisi
- Sección de Alergia Pediátrica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - N Petriz
- Sección de Alergia Pediátrica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - C Parente
- Sección de Alergia Pediátrica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M B Jauregui
- Servicio de Alimentación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - V Pagoto
- Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
7
|
Zain-Alabedeen S, Kamel N, Amin M, Vernon-Roberts A, Day AS, Khashana A. Fecal Calprotectin and Cow's Milk-Related-Symptoms Score in Children with Cow's Milk Protein Allergy. Pediatr Gastroenterol Hepatol Nutr 2023; 26:43-49. [PMID: 36816436 PMCID: PMC9911171 DOI: 10.5223/pghn.2023.26.1.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/21/2022] [Accepted: 10/07/2022] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The cow's milk-related-symptom-score (CoMiSS) tool was developed as an awareness tool for the assessment of cow's milk-related symptoms in infants or children. Fecal calprotectin (FC) is a noninvasive biomarker of gut inflammation that can be measured in serum and stool. This study aimed to investigate the relationship between FC levels and CoMiSS scores in infants with cow's milk protein allergy. METHODS Infants (aged 6-12 months) who were allergic to cow's milk protein were enrolled prospectively. Following completion of the CoMiSS scoring, the infants were divided into group 1 (positive CoMiSS scores ≥12) and group 2 (negative CoMiSS scores <12). FC was measured using immunoassay. RESULTS Of the 120 infants enrolled in this study, 60 (50.0%) had positive CoMiSS scores (group 1), while 60 (50.0%) had negative scores (group 2). The mean FC level was higher in the infants in group 1 than those in group 2 (2,934.57 µg/g vs. 955.13 µg/g; p<0.001). In addition, there was a positive correlation between FC and CoMiSS scores (R=0.168, p<0.0001). A FC level of 1,700 µg/g provided a sensitivity of 98.3%, specificity of 93.3%, and accuracy of 95.8% for the diagnosis of cow's milk protein allergy (CMPA). CONCLUSION FC measurement may have a role in the assessing infants with CMPA.
Collapse
Affiliation(s)
| | - Noha Kamel
- Department of Pathology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mona Amin
- Department of Pediatrics, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Andrew S Day
- Department of Paediatrics, University of Otago Christchurch, Christchurch, New Zealand
| | - Abdelmoneim Khashana
- Department of Pediatrics, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| |
Collapse
|
8
|
Vandenplas Y, Bajerova K, Dupont C, Eigenmann P, Kuitunen M, Meyer R, Ribes-Koninckx C, Salvatore S, Shamir R, Szajewska H. The Cow's Milk Related Symptom Score: The 2022 Update. Nutrients 2022; 14:nu14132682. [PMID: 35807862 PMCID: PMC9268587 DOI: 10.3390/nu14132682] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/22/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
CoMiSS® was developed 7 years ago to increase the awareness of health care professionals towards the possibility that symptoms presented by infants could be related to cow’s milk. While CoMiSS was conceived mostly on theoretical concepts, data is now available from 25 clinical trials. Based on this extensive research using the tool since 2015, we aim to propose an updated CoMiSS. The evidence was reviewed, debated and discussed by 10 experts, of whom seven were part of the original group. The panel concluded that the cut-off previously proposed to indicate the likelihood that symptoms may be cow’s milk related should be lowered from ≥12 to ≥10. Data in healthy infants > 6 months are missing. Since the Brussels Infant and Toddlers Stool Scale (BITSS) was recently developed for non-toilet trained children, the Bristol Stool Scale was changed to the BITSS without changing the impact of stool characteristics on CoMiSS. Overall, CoMiSS raises awareness that symptoms might be cow’s milk related. New studies are needed to determine if the change in cut-off and other small adaptions improve its sensitivity and specificity. Data for CoMiSS is still needed in presumed healthy infants between 6 and 12 months old. There may also be regional differences in CoMiSS, in healthy infants as well as in those with cow’s milk allergy. Finally, we emphasize that CoMiSS is an awareness tool and not a diagnostic test.
Collapse
Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Laarbeeklaan 101, 1090 Brussels, Belgium
- Correspondence: ; Tel.: +32-475748794
| | - Katerina Bajerova
- Department of Pediatrics, University Hospital Brno and Masaryk’s University, 625 00 Brno, Czech Republic;
- Department of Internal Medicine, Geriatrics and Practical Medicine, University Hospital Brno and Masaryk´s University, 625 00 Brno, Czech Republic
| | - Christophe Dupont
- Ramsay Group, France et Clinique Marcel Sembat, Paris Descartes University, Boulogne-Billancourt, 75004 Paris, France;
| | - Philippe Eigenmann
- Pediatric Allergy Unit, University Hospitals of Geneva, 1205 Geneva, Switzerland;
| | - Mikael Kuitunen
- Children’s Hospital, University of Helsinki and Helsinki University Hospital, 00290 Helsinki, Finland;
| | - Rosan Meyer
- Department Paediatrics, Imperial College London, London SW7 2BX, UK;
- Department Dietetics, Winchester University, Winchester SO23 4NR, UK
- Department Medicine, KU Leuven, 3001 Leuven, Belgium
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology, La Fe University Hospital, Instituto de Iinvestigacion Sanitaria La FE Valencia, 46026 Valencia, Spain;
| | - Silvia Salvatore
- Department of Paediatrics, University of Insubria, 21100 Varese, Italy;
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center, Lea and Arieh Pickel for Pediatric Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 69978, Israel;
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, 02-014 Warsaw, Poland;
| |
Collapse
|
9
|
The Cow's Milk-Related Symptom Score (CoMiSS ™): A Useful Awareness Tool. Nutrients 2022; 14:nu14102059. [PMID: 35631201 PMCID: PMC9146599 DOI: 10.3390/nu14102059] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 04/28/2022] [Accepted: 05/11/2022] [Indexed: 12/15/2022] Open
Abstract
The Cow’s Milk-related Symptom Score (CoMiSS™) was developed as a clinical tool aimed at increasing the awareness of health care professionals for the presence and intensity of clinical manifestations possibly related to cow’s milk (CM) intake. This review summarizes current evidence on CoMiSS. We found twenty-five original studies, one pooled analysis of three studies, and two reviews on CoMiSS. Infants exhibiting symptoms possibly related to CM, present with a higher median CoMiSS (6 to 13; 16 studies) than apparently healthy infants (median from 3 to 4; and mean 3.6−4.7; 5 studies). In children with cow’s milk allergy (CMA), 11 studies found that a CoMiSS of ≥12 predicted a favorable response to a CM-free diet; however, sensitivity (20% to 77%) and specificity (54% to 92%) varied. The decrease of CoMiSS during a CM elimination diet was also predictive of a reaction to an oral food challenge to diagnose CMA. A low CoMiSS (<6) was predictive for the absence of CMA. It was shown that no special training is required to use the tool in a reliable way. Intra-rater reliability was high with very low variability (intra-class correlation 0.93; 95% confidence interval 0.90−0.96; p < 0.001) in repeated assessments. This review found that CoMiSS cannot be considered as a stand-alone CMA diagnostic tool, but that it is a useful awareness tool for CMA as well as for monitoring symptom improvement.
Collapse
|
10
|
Toca MC, Morais MB, Vázquez-Frias R, Becker-Cuevas DJ, Boggio-Marzet CG, Delgado-Carbajal L, Higuera-Carrillo MM, Ladino L, Marchisone S, Messere GC, Ortiz GJ, Ortiz-Paranza LR, Ortiz-Piedrahita C, Riveros-López JP, Sosa PC, Villalobos-Palencia NC. Consensus on the diagnosis and treatment of cow's milk protein allergy of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2022; 87:235-250. [PMID: 35623990 DOI: 10.1016/j.rgmxen.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein.
Collapse
Affiliation(s)
- M C Toca
- Sección Gastroenterología, Hepatología y Nutrición, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - M B Morais
- Escuela Paulista de Medicina, Universidad Federal de Sao Paulo, Sao Paulo, Brazil
| | - R Vázquez-Frias
- Departamento de Gastroenterología y Nutrición, Instituto Nacional de Salud Hospital Infantil de México Federico Gómez, Mexico City, Mexico.
| | - D J Becker-Cuevas
- Servicio de Pediatría, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - C G Boggio-Marzet
- Gastroenterología y Nutrición Pediátrica, División Pediatría, Departamento Materno Infanto Juvenil, Hospital Gral. de Agudos «Dr. I. Pirovano», Ciudad Autónoma de Buenos Aires, Argentina
| | - L Delgado-Carbajal
- Servicio de Gastroenterología, Hepatología y Nutrición Pediátrica, Unidad de Endoscopia Digestiva Pediátrica, Hospital Universitario «Centro Hospitalario Pereira Rossell», Montevideo, Uruguay
| | | | - L Ladino
- Instituto de Investigación en Nutrición, Genética y Metabolismo IINGM, Facultad de Medicina, Universidad El Bosque, Bogotá, Colombia
| | - S Marchisone
- Servicio de Gastroenterología, Hospital Infantil de Córdoba, Córboba, Argentina
| | - G C Messere
- Sección Gastroenterología, Hepatología y Nutrición, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - G J Ortiz
- Sección de Gastroenterología, Hepatología y Nutrición Infantil, Servicio de Pediatría, Hospital Nacional Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | - L R Ortiz-Paranza
- Hospital General Pediátrico «Niños de Acosta Ñu», Ministerio de Salud Pública y Bienestar Social, San Lorenzo, Paraguay
| | - C Ortiz-Piedrahita
- Departamento de Pediatría, Servicio de Gastroenterología Infantil, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - J P Riveros-López
- Unidad de Gastroenterología Pediátrica Juan Pablo Riveros SAS, Bogotá, Colombia
| | - P C Sosa
- Sección Gastroenterología, Hepatología y Nutrición Infantil, Servicio de Pediatría, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | | |
Collapse
|
11
|
Connor F, Salvatore S, D’Auria E, Baldassarre ME, Acunzo M, Di Bella G, Farella I, Sestito S, Pensabene L. Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review. Nutrients 2022; 14:1317. [PMID: 35334974 PMCID: PMC8955686 DOI: 10.3390/nu14061317] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/02/2022] [Accepted: 03/17/2022] [Indexed: 12/11/2022] Open
Abstract
Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35-52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows' milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows' milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0-17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows' milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.
Collapse
Affiliation(s)
- Frances Connor
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children’s Hospital, Brisbane 4101, Australia;
- Mayne Academy of Pediatrics, Faculty of Medicine, University of Queensland, Brisbane 4101, Australia
| | - Silvia Salvatore
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy; (S.S.); (G.D.B.)
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.A.)
| | - Maria Elisabetta Baldassarre
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Miriam Acunzo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.A.)
| | - Gaia Di Bella
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy; (S.S.); (G.D.B.)
| | - Ilaria Farella
- Department of Biomedical Science and Human Oncology, Clinica Medica “A. Murri”, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Simona Sestito
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| |
Collapse
|
12
|
Managing Cow's Milk Protein Allergy with an Extensively Hydrolyzed Formula: Results from a Prospective, Non-Interventional Study in France (EVA Study). Nutrients 2022; 14:nu14061203. [PMID: 35334859 PMCID: PMC8952694 DOI: 10.3390/nu14061203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Symptoms related cow’s milk proteins allergy (CMPA) usually improve between two to four weeks following an elimination diet, firstly with extensively hydrolyzed formulas (eHF). The aim of the EVA study was to observe the evolution of CMPA-related symptoms in real life after initiation of a whey-based extensively hydrolyzed formula (w-eHF, Althéra®, Nestlé Health Science, Switzerland). This cross-sectional prospective non-interventional study was carried out alongside paediatricians in private practice in France between June 2019 and June 2020. Infants aged 0−3 years presenting with confirmed diagnosis or clinical symptoms suggesting CMPA were enrolled. Data were collected at enrolment (baseline visit) and three to five weeks later (follow-up visit). Symptoms were assessed using the Cow’s Milk-related Symptom Score (CoMiSS®). The per protocol population included 135 infants. The average number of symptoms per infant significantly decreased under the study formula (from 2.81 to 1.36, p < 0.001) and the proportions of infants with any CMPA related symptoms decreased. Daily crying and regurgitation showed the largest decline, respectively −44.4% and −31.85% (p < 0.001). These results describe the early management of symptoms suspected to be related to CMPA in routine practice that was rarely described in the literature. The number and severity of symptoms decreased most of the cases after commencing the study formula.
Collapse
|
13
|
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.
Collapse
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
| | | | | |
Collapse
|
14
|
Vandenplas Y, Żołnowska M, Berni Canani R, Ludman S, Tengelyi Z, Moreno-Álvarez A, Goh AEN, Gosoniu ML, Kirwan BA, Tadi M, Heine RG. Effects of an Extensively Hydrolyzed Formula Supplemented with Two Human Milk Oligosaccharides on Growth, Tolerability, Safety and Infection Risk in Infants with Cow's Milk Protein Allergy: A Randomized, Multi-Center Trial. Nutrients 2022; 14:530. [PMID: 35276889 PMCID: PMC8839689 DOI: 10.3390/nu14030530] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 02/04/2023] Open
Abstract
This randomized clinical trial (Registration: NCT03085134) assessed if an extensively hydrolyzed formula (EHF) supplemented with two human milk oligosaccharides (HMO) and reduced protein content (2.20 g/100 kcal) supports normal growth in infants with cow’s milk protein allergy (CMPA). Secondary outcomes were gastrointestinal tolerability, safety, and effect on infections. Nonbreastfed infants aged 0−6 months with CMPA were enrolled. Body weight, length, and head circumference were measured monthly for 4 months (primary study endpoint), after 6 months, and at the age of 12 months. Of 200 infants screened, 194 (mean age 3.2 months) were randomized. At the 4-month follow-up, daily weight gain for the test formula was noninferior to the control formula; p < 0.005. There were no significant group differences in anthropometric parameters. Both formulas were safe and well tolerated. Infants in the HMO group had a statistically significant reduction in the frequency of upper respiratory tract infections and a lower incidence of ear infections at 12 months (per protocol analysis). The relative risk of lower respiratory tract and gastrointestinal infections was reduced by 30−40%, but this was not statistically significant due to sample size limitations. In summary, the HMO-supplemented formula supports normal growth in infants with CMPA and suggests a protective effect against respiratory and ear infections in the first year of life.
Collapse
Affiliation(s)
- Yvan Vandenplas
- UZ Brussel KidZ Health Castle, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | | | - Roberto Berni Canani
- Department of Translational Medical Science, University Federico II, 80131 Naples, Italy;
| | - Siân Ludman
- Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, UK;
| | | | - Ana Moreno-Álvarez
- Department of Pediatrics, A Coruña University Hospital, 15006 A Coruña, Spain;
| | - Anne E. N. Goh
- KK Women’s and Children’s Hospital, Singapore 229899, Singapore;
| | | | | | - Monika Tadi
- Nestlé Health Science, 1800 Vevey, Switzerland; (M.T.); (R.G.H.)
| | - Ralf G. Heine
- Nestlé Health Science, 1800 Vevey, Switzerland; (M.T.); (R.G.H.)
| | | |
Collapse
|
15
|
Thompson G, Zhelev Z, Peters J, Khalid S, Briscoe S, Shaw L, Nunns M, Ludman S, Hyde C. Symptom scores in the diagnosis of pediatric cow's milk protein allergy: A systematic review. Pediatr Allergy Immunol 2021; 32:1497-1507. [PMID: 33971057 DOI: 10.1111/pai.13537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cow's milk protein allergy (CMPA) is an immune-mediated allergic response to proteins in milk that is common in infants. Broad CMPA symptoms make diagnosis a challenge, particularly in primary care. Symptom scores may improve a clinician's awareness of symptoms, indicating a need for further testing. This systematic review examined the development and evaluation of such symptom scores for use in infants. METHODS CENTRAL, MEDLINE, EMBASE and CINAHL databases were searched from inception to 3 December 2019 (Updated 14 November 2020) for diagnostic accuracy studies, randomised controlled trials, observational studies, economic evaluations, qualitative studies and studies reporting development of the tools. Data were not suitable for meta-analysis due to clinical and methodological heterogeneity, so were narratively synthesised. RESULTS We found two symptom scores evaluated in one and fourteen studies, respectively. Estimated sensitivity and specificity ranged from 37% to 98% and 38% to 93%. The evaluations of each tool were at high risk of bias or failed to address issues such as clinical and cost-effectiveness. CONCLUSIONS Estimates of accuracy of symptom scores for CMPA offered so far should be interpreted cautiously. Rigorous, conflict-free research based on well-defined roles for the tools is urgently required.
Collapse
Affiliation(s)
- Georgina Thompson
- Exeter Test Group, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Zhivko Zhelev
- Exeter Test Group, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jaime Peters
- Exeter Test Group, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Sara Khalid
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Simon Briscoe
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Michael Nunns
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Sian Ludman
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Christopher Hyde
- Exeter Test Group, University of Exeter Medical School, University of Exeter, Exeter, UK
| |
Collapse
|
16
|
Vandenplas Y, Belohlavkova S, Enninger A, Frühauf P, Makwana N, Järvi A. How Are Infants Suspected to Have Cow's Milk Allergy Managed? A Real World Study Report. Nutrients 2021; 13:nu13093027. [PMID: 34578905 PMCID: PMC8464701 DOI: 10.3390/nu13093027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022] Open
Abstract
The purpose of this study was to evaluate the diagnosis and management of infants presenting with symptoms attributable to cow’s milk allergy (CMA) in a real life setting and to test how the Cow’s Milk-related Symptom Score (CoMiSS®) can be used to support the awareness to diagnose cow’s milk protein allergy in primary care practice. The CoMiSS is an awareness tool based on various symptoms such as crying, gastrointestinal symptoms, dermatological and respiratory symptoms. The study was conducted on 268 infants from four countries (Belgium, Czech Republic, Germany, UK) aged 0 to 18 months consulting for CMA related symptoms. The analysis was based on two visits of these subjects. The results show an average CoMiSS of 11 at the first visit. After a therapeutic dietary intervention, the score at the second visit, which happened 3 weeks ± 5 days after the first one, dropped to an average value of 4. A satisfaction questionnaire completed by the primary care practitioners suggested an overall high level of satisfaction with the application of the CoMiSS tool in routine practice. These data highlight a huge discrepancy in the diagnosis and management of infants suspected of CMA in the different countries. The findings suggest that the CoMISS questionnaire is an effective tool in aiding awareness of CMPA in primary health care.
Collapse
Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, 1090 Brussels, Belgium
- Correspondence: ; Tel.: +32-475-748-794
| | | | - Axel Enninger
- Olgahospital, Zentrum für Kinder-, Jugend- und Frauenmedizin, Klinikum Stuttgart, 70174 Stuttgart, Germany;
| | - Pavel Frühauf
- Pediatric Clinics and Inherited Metabolic Disorders, 1st Faculty of Medicine Charles University, 12108 Prague, Czech Republic;
| | - Niten Makwana
- Sandwell and West Birmingham Hospitals, Birmingham B18 7QH, UK;
| | | |
Collapse
|
17
|
D’Auria E, Salvatore S, Acunzo M, Peroni D, Pendezza E, Di Profio E, Fiore G, Zuccotti GV, Verduci E. Hydrolysed Formulas in the Management of Cow's Milk Allergy: New Insights, Pitfalls and Tips. Nutrients 2021; 13:2762. [PMID: 34444922 PMCID: PMC8401609 DOI: 10.3390/nu13082762] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 12/12/2022] Open
Abstract
An allergy to cow's milk requires the avoidance of cow's milk proteins and, in some infants, the use of a hypoallergenic formula. This review aims to summarize the current evidence concerning different types of hydrolysed formulas (HF), and recommendations for the treatment of IgE- and non-IgE-mediated cow's milk allergy and functional gastrointestinal disorders in infancy, for which some dietary intervention and HF may be of benefit to both immune and motor mechanisms. Current guidelines recommend cow's milk protein (i.e., whey or casein) extensively hydrolysed formula (eHF) as the first choice for cow's milk allergy treatment, and amino acid formulas for more severe cases or those with reactions to eHF. Rice hydrolysed formulas (rHF) have also become available in recent years. Both eHF and rHF are well tolerated by the majority of children allergic to cow's milk, with no concerns regarding body growth or adverse effects. Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics. Despite encouraging results on tolerance acquisition, evidence is still not conclusive, thus hampering our ability to draw firm conclusions. In clinical practice, the choice of hypoallergenic formula should be based on the infant's age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy.
Collapse
Affiliation(s)
- Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Silvia Salvatore
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy;
| | - Miriam Acunzo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, 56126 Pisa, Italy;
| | - Erica Pendezza
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Elisabetta Di Profio
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Giulia Fiore
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Gian Vincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| |
Collapse
|
18
|
Kozłowska-Jalowska A, Horvath A, Vandenplas Y, Szajewska H. Retrospective and Prospective Determination of the Cow's Milk-Related Symptom Score (CoMiSS™) Values in Symptomatic Infants. Pediatr Gastroenterol Hepatol Nutr 2021; 24:384-391. [PMID: 34316473 PMCID: PMC8279825 DOI: 10.5223/pghn.2021.24.4.384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/20/2021] [Accepted: 05/15/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The Cow's Milk-related Symptom Score (CoMiSS™) was developed as an awareness tool for evaluating cow's milk-related symptoms in otherwise healthy children. Using a convenience sample of participants, this cross-sectional study aimed to determine CoMiSS™ values of symptomatic infants based on retrospectively or prospectively obtained information. METHODS CoMiSS™ values were determined in infants aged <12 months with symptoms suggestive of cow's milk protein allergy or functional gastrointestinal disorders. The exclusion criteria were previous diagnosis with acute or chronic disease, treatment with a therapeutic formula, and in case of breastfeeding, an elimination diet followed by the mother. Two CoMiSS™ values were assessed. A retrospective collection was defined as the collection of data after initial contact with the medical center but before the first medical consultation. A prospective collection was defined as the collection of data within 24 hours from the time of medical consultation but before starting any therapeutic intervention. The CoMiSS™ total and individual component scores obtained retrospectively or prospectively were compared between groups using the Wilcoxon signed-rank test. RESULTS This study was performed between August and November 2019. Data of 110 children (62 males and 48 females), with a mean±standard deviation age of 18.2±11.7 weeks, were obtained. The total CoMiSS™ value (p<0.001) and some individual component scores (crying, regurgitation, and stool) were significantly lower when collected prospectively than when collected retrospectively. CONCLUSION CoMiSS™ values were retrospectively and prospectively determined. Lower CoMiSS™ values were obtained during prospective evaluation. Possible differences should be considered when using CoMiSS™ in clinical practice.
Collapse
Affiliation(s)
| | - Andrea Horvath
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
19
|
Salvatore S, Agosti M, Baldassarre ME, D’Auria E, Pensabene L, Nosetti L, Vandenplas Y. Cow's Milk Allergy or Gastroesophageal Reflux Disease-Can We Solve the Dilemma in Infants? Nutrients 2021; 13:297. [PMID: 33494153 PMCID: PMC7909757 DOI: 10.3390/nu13020297] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Cow's milk allergy (CMA) and gastro-esophageal reflux disease (GERD) may manifest with similar symptoms in infants making the diagnosis challenging. While immediate reaction to cow's milk protein indicate CMA, regurgitation, vomiting, crying, fussiness, poor appetite, sleep disturbances have been reported in both CMA and GERD and in other conditions such as functional gastrointestinal disorders, eosinophilic esophagitis, anatomic abnormalities, metabolic and neurological diseases. Gastrointestinal manifestations of CMA are often non-IgE mediated and clinical response to cow's milk free diet is not a proof of immune system involvement. Neither for non-IgE CMA nor for GERD there is a specific symptom or diagnostic test. Oral food challenge, esophageal pH impedance and endoscopy are recommended investigations for a correct clinical classification but they are not always feasible in all infants. As a consequence of the diagnostic difficulty, both over- and under- diagnosis of CMA or GERD may occur. Quite frequently acid inhibitors are empirically started. The aim of this review is to critically update the current knowledge of both conditions during infancy. A practical stepwise approach is proposed to help health care providers to manage infants presenting with persistent regurgitation, vomiting, crying or distress and to solve the clinical dilemma between GERD or CMA.
Collapse
Affiliation(s)
- Silvia Salvatore
- Department of Medicine and Surgery, Pediatric Unit, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy; (M.A.); (L.N.)
| | - Massimo Agosti
- Department of Medicine and Surgery, Pediatric Unit, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy; (M.A.); (L.N.)
| | - Maria Elisabetta Baldassarre
- Department of Biomedical Sciences and Human Oncology-Neonatology and NICU Section, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy;
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Luana Nosetti
- Department of Medicine and Surgery, Pediatric Unit, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy; (M.A.); (L.N.)
| | - Yvan Vandenplas
- Kidz Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium;
| |
Collapse
|
20
|
Calvani M, Anania C, Cuomo B, D’Auria E, Decimo F, Indirli GC, Marseglia G, Mastrorilli V, Sartorio MUA, Santoro A, Veronelli E. Non-IgE- or Mixed IgE/Non-IgE-Mediated Gastrointestinal Food Allergies in the First Years of Life: Old and New Tools for Diagnosis. Nutrients 2021; 13:226. [PMID: 33466746 PMCID: PMC7829867 DOI: 10.3390/nu13010226] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/06/2021] [Accepted: 01/09/2021] [Indexed: 12/11/2022] Open
Abstract
non-IgE and mixed gastrointestinal food allergies present various specific, well-characterized clinical pictures such as food protein-induced allergic proctocolitis, food protein-induced enterocolitis and food protein-induced enteropathy syndrome as well as eosinophilic gastrointestinal disorders such as eosinophilic esophagitis, allergic eosinophilic gastroenteritis and eosinophilic colitis. The aim of this article is to provide an updated review of their different clinical presentations, to suggest a correct approach to their diagnosis and to discuss the usefulness of both old and new diagnostic tools, including fecal biomarkers, atopy patch tests, endoscopy, specific IgG and IgG4 testing, allergen-specific lymphocyte stimulation test (ALST) and clinical score (CoMiss).
Collapse
Affiliation(s)
- Mauro Calvani
- Operative Unit of Pediatrics, S. Camillo-Forlanini Hospital, 00152 Rome, Italy
| | - Caterina Anania
- Immunology and Allergology Unit, Department of Mother-Child, Urological Science, Sapienza University of Rome, 00161 Rome, Italy;
| | - Barbara Cuomo
- Operative Complex Unit of Pediatrics, Belcolle Hospital, 00100 Viterbo, Italy;
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.U.A.S.)
| | - Fabio Decimo
- Department of Woman, Child and of General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80100 Naples, Italy;
| | - Giovanni Cosimo Indirli
- Pediatric Allergology and Immunology (SIAIP) for Regions Puglia and Basilicata, 73100 Lecce, Italy;
| | - Gianluigi Marseglia
- Pediatric Clinic, Pediatrics Department, Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy;
| | - Violetta Mastrorilli
- Operative Complex Unit of Pediatrics and Emergency, Giovanni XXIII Hospital, 70056 Bari, Italy;
| | - Marco Ugo Andrea Sartorio
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.U.A.S.)
| | - Angelica Santoro
- Pediatric Clinic, Mother-Child Department, University of Parma, 43121 Parma, Italy;
| | - Elisabetta Veronelli
- Food Allergy Committee of the Italian Society of Pediatric Allergy and Immunology (SIAIP), Pediatric Department, Garbagnate Milanese Hospital, ASST Rhodense, 70056 Garbagnate Milanese, Italy;
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW The aim of this review is to describe the role of precision medicine in the diagnosis, treatment, and monitoring of cow's milk allergy. RECENT FINDINGS The development of 'omics' sciences in the field of food allergy has led to a better understanding of the allergenicity of cow's milk proteins and significant advances in the knowledge of the pathogenesis and mechanisms of cow's milk allergy. Omics-based technologies allow the practitioner to better differentiate cow's milk allergy subtypes and to predict cow's milk allergy (CMA) persistence over time. Precision medicine extends the role of the oral food challenge, to determine the individual's threshold doses, and to establish tolerance to baked milk products. Other than symptom relief, dietary strategies are currently being investigated for the potential to induce tolerance. Oral immunotherapy offers a treatment option for patients with severe and persistent IgE-mediated CMA. Individual baseline-immune profiles may be predictive of cow's milk oral immunotherapy safety and efficacy.Patient data derived from current technology, in combination with the patient's history, can be translated into treatments targeted at patient-tailored interventions. SUMMARY The identification of novel biomarkers may improve diagnostic accuracy and also predict patient responsiveness to treatments. Integration of patient data will become increasingly important as omics technologies become more widely used in the clinical setting.
Collapse
|
22
|
May Failure to Thrive in Infants Be a Clinical Marker for the Early Diagnosis of Cow's Milk Allergy? Nutrients 2020; 12:nu12020466. [PMID: 32069783 PMCID: PMC7071281 DOI: 10.3390/nu12020466] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/07/2020] [Accepted: 02/09/2020] [Indexed: 01/13/2023] Open
Abstract
Objectives—Failure to thrive (FTT) in infants is characterized by growth failure. Although, cow’s milk allergy (CMA) may have an impact on growth and leads to FTT, data are still limited. We focused on FTT as a possible clinical marker for an early diagnosis of CMA. The aim of the present study was to evaluate the implications of cow’s milk hypersensitivity in infants with FTT and the growth catch-up after a cow’s milk-free diet (CMFD). Methods—A cross-sectional study of all consecutive infants evaluated at the Pediatric Nutrition and Allergy Unit of the University Hospital of Bari (Italy) from January 2016 to April 2018 with a medical-driven diagnosis of FTT. Eligible infants were investigated for possible IgE mediated or non-IgE mediated CMA. Results—43 infants were included, mean age 5.7 months. 33/43 (77%) FTT presented a CMA related disease: 3/43 (7%) were diagnosed as presenting an IgE mediated CMA, 30 (93%) had a non IgE-mediated CMA, confirmed by the elimination diet for diagnostic purposes, that led to a significant improvement of symptoms and recrudescence after milk reintroduction. A total of 29 out of 30 patients (one patient was lost at follow-up) moved up to their original growth percentile after dietary changes. Growth z-scores were computed based on WHO anthropometric data. In 10 out of 43 patients (23%) were diagnosed with gastro-esophageal reflux disease (GERD). Conclusions—when evaluating an infant with FTT, physicians should include in their evaluation an extensive search for IgE mediated and non IgE mediated CMA. When in vivo and in vitro analysis are not conclusive, a 4- to 8-weeks trial of CMFD and a consecutive re-introduction of milk proteins may be helpful in less common diagnoses.
Collapse
|
23
|
Vandenplas Y, Carvajal E, Peeters S, Balduck N, Jaddioui Y, Ribes-Koninckx C, Huysentruyt K. The Cow's Milk-Related Symptom Score (CoMiSS TM): Health Care Professional and Parent and Day-to-Day Variability. Nutrients 2020; 12:E438. [PMID: 32050456 PMCID: PMC7071294 DOI: 10.3390/nu12020438] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/06/2020] [Accepted: 02/07/2020] [Indexed: 02/07/2023] Open
Abstract
The Cow's Milk-related Symptom Score (CoMiSSTM) was created as an awareness tool for cow's milk allergy. The aim of the present study was to analyze the inter-rater variability between a pediatrician, parents, and day to day variability. A Health Care Professional (HCP) and parent filled in the CoMiSS independently and blinded for each other to evaluate inter-rater variability. In order to validate day-to-day variability, a parent filled in the CoMiSS during 3 consecutive days and was compared to the CoMiSS scored by the HCP. The absolute agreement between parent and HCP was 75%, and 92.6% and 100% with a tolerance of 0, 1, and 2 points, respectively, resulting in excellent agreement with an intraclass correlation coefficient (ICC) 0.981 (95% Confidence Interval 0.974-0.986, p < 0.001). Day-to-day variability during 3 consecutive days resulted in an absolute agreement of 30%, increasing to 80% and 88.6% when 2 and 3 points, respectively, were accepted. The ICC was excellent for the parental prospective scores (0.93, 95% CI 0.90-0.96; p < 0.001). Day-to-day variability indicates that CoMiSS has a moderate inter-rater reliability. A very low variability was observed when scored prospectively over three days. Data suggest that the CoMiSS can reliably be scored by parents without additional training.
Collapse
Affiliation(s)
- Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Brussels, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (N.B.); (K.H.)
| | - Eva Carvajal
- Department of Paediatrics, Hospital Casa de Salud, 46021 Valencia, Spain;
| | | | - Nadine Balduck
- KidZ Health Castle, UZ Brussel, Brussels, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (N.B.); (K.H.)
| | - Yesra Jaddioui
- KidZ Health Castle, UZ Brussel, Brussels, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (N.B.); (K.H.)
| | - Carmen Ribes-Koninckx
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, La Fe University Hospital, 46026 Valencia, Spain;
| | - Koen Huysentruyt
- KidZ Health Castle, UZ Brussel, Brussels, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (N.B.); (K.H.)
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
| |
Collapse
|