Growth in Infants with Cow's Milk Protein Allergy Fed an Amino Acid-Based Formula

Growth in healthy infants with cow's milk protein allergy fed extensively hydrolyzed or amino acid-based formulas

BACKGROUND

Cow's milk protein allergy (CMPA) is one of the most common food allergies in the first year of life. Special formulas for infants with CMPA include extensively hydrolyzed (EHFs) and amino acid-based (AAFs) formulas. The aim of this study was to evaluate the growth of infants fed with these special formulas.

METHODS

This was a prospective chart review study that evaluated the growth criteria of infants with CMPA fed with EHFs or AAFs until one year of age. These infants were referred to the gastroenterology clinic of Bahrami Children's Hospital from April 2021 to April 2022. These infants were divided into two groups, the group fed with EHFs and AAFs. Then growth criteria were evaluated in both groups.

RESULTS

Fifty-eight children were enrolled in the study, of which 51.7% were girls. Forty were consuming the EHFs formulas. The median time of both diagnosis and treatment was 60 days. The most common clinical manifestations were gastroesophageal reflux, dysentery, eczema, vomiting, and cough, respectively. The diagnosis of the disease in the AAFs group was significantly earlier than in the other group. The growth of children in both groups was completely proportional to their age and growth criteria at birth. Comparing the groups, all growth parameters were higher in the EHFs group.

CONCLUSION

This study showed that the growth criteria (weight, length, and head circumference) were suitable for each group and were in accordance with the WHO growth charts compared to the birth criteria. But in the group fed with EHFs, compared to AAFs, the growth rate was higher.

Growth and Nutritional Biomarkers in Brazilian Infants with Cow's Milk Allergy at Diagnosis and 18-Month Follow-Up: A Prospective Cohort Study

Purpose

This study aimed to describe the growth, body protein status, and micronutrient biomarkers of Brazilian infants with cow's milk allergy (CMPA) at baseline and at 18 months of follow-up in comparison with their healthy peers.

Methods

Thirty infants with CMPA younger than six months of age were included in this longitudinal study, and their nutritional status was compared with that of 24 non-allergic age-matched children. Anthropometric measurements were used to assess growth, and blood and urine samples were analyzed for protein and micronutrient status. Mixed linear models adjusted for birth weight, socioeconomic status, infant feeding at baseline, weight-for-age, C-reactive protein, serum albumin, micronutrient dietary supplementation, and salt consumption were employed to evaluate the evolution of nutritional parameters throughout the follow-up period.

Results

Overall, the mean age of the children at enrolment was 2.9 (standard deviation 1.7) months, and 29 children (53.7%) were male. Infants with CMPA showed a higher prevalence of functional iron depletion (transferrin saturation <20) (p=0.027), lower serum ferritin (p=0.009), and lower urinary iodine (p=0.034) levels than non-allergic children at baseline. Patients with CMPA showed a higher increment in weight-for-age and length-for-age over time than those in the control group (p<0.01). Mixed linear analyses showed a significantly lower increase in serum vitamin B12 (s-B12) (p=0.001) and urinary iodine (p<0.001) concentrations over time compared to the control group.

Conclusion

Infants with CMPA on a cow's milk elimination diet had a higher weight and length at 18 months of follow-up but showed signs of inadequate iron, iodine, and B-12 vitamin status.

Nutritional Strategies for the Prevention and Management of Cow's Milk Allergy in the Pediatric Age

Cow's milk allergy (CMA) is one of the most common pediatric food allergies. The prevalence and severity of CMA have increased dramatically in the last decades, under the pressure of environmental factors in genetically predisposed individuals. Among the environmental influences, nutritional factors play a crucial role. Diet is the most modifiable factor, representing a potential target for the prevention and treatment of CMA. In this review, we report the most scientific-based nutritional strategies for preventing and managing pediatric CMA. In addition, we propose the most complete supplement of compounds able to prevent nutrient deficiencies in CMA pediatric patients and to positively influence the disease course.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of an Amino Acid-Based Formula Supplemented with Two Human Milk Oligosaccharides on Growth, Tolerability, Safety, and Gut Microbiome in Infants with Cow's Milk Protein Allergy

This open-label, non-randomized, multicenter trial (Registration: NCT03661736) aimed to assess if an amino acid-based formula (AAF) supplemented with two human milk oligosaccharides (HMO) supports normal growth and is well tolerated in infants with a cow's milk protein allergy (CMPA). Term infants aged 1-8 months with moderate-to-severe CMPA were enrolled. The study formula was an AAF supplemented with 2'-fucosyllactose (2'-FL) and lacto-N-neotetraose (LNnT). Infants were fed the study formula for 4 months and were offered to remain on the formula until 12 months of age. Tolerance and safety were assessed throughout the trial. Out of 32 infants (mean age 18.6 weeks; 20 (62.5%) male), 29 completed the trial. During the 4-month principal study period, the mean weight-for-age Z score (WAZ) increased from -0.31 at the baseline to +0.28 at the 4-months' follow-up. Linear and head growth also progressed along the WHO child growth reference, with a similar small upward trend. The formula was well tolerated and had an excellent safety profile. When comparing the microbiome at the baseline to the subsequent visits, there was a significant on-treatment enrichment in HMO-utilizing bifidobacteria, which was associated with a significant increase in fecal short-chain fatty acids. In addition, we observed a significant reduction in the abundance of fecal Proteobacteria, suggesting that the HMO-supplemented study formula partially corrected the gut microbial dysbiosis in infants with CMPA.

Alternatives to Cow’s Milk-Based Infant Formulas in the Prevention and Management of Cow’s Milk Allergy

Cow’s milk-based infant formulas are the most common substitute to mother’s milk in infancy when breastfeeding is impossible or insufficient, as cow’s milk is a globally available source of mammalian proteins with high nutritional value. However, cow’s milk allergy (CMA) is the most prevalent type of food allergy among infants, affecting up to 3.8% of small children. Hypoallergenic infant formulas based on hydrolysed cow’s milk proteins are commercially available for the management of CMA. Yet, there is a growing demand for more options for infant feeding, both in general but especially for the prevention and management of CMA. Milk from other mammalian sources than the cow, such as goat, sheep, camel, donkey, and horse, has received some attention in the last decade due to the different protein composition profile and protein amino acid sequences, resulting in a potentially low cross-reactivity with cow’s milk proteins. Recently, proteins from plant sources, such as potato, lentil, chickpeas, quinoa, in addition to soy and rice, have gained increased interest due to their climate friendly and vegan status as well as potential lower allergenicity. In this review, we provide an overview of current and potential future infant formulas and their relevance in CMA prevention and management.

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)

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.

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

ABSTRACT

Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them.

CONCLUSION

A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.