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Li T, Zheng Q, Zhang M, Li Y, Zhou Y, Xu C, Zhang B, Wang Z, Tian J, Zhou L. How consistent are the key recommendations, and what is the quality of guidelines and expert consensus regarding paediatric cow's milk protein allergy? Eur J Pediatr 2024:10.1007/s00431-024-05622-3. [PMID: 38809454 DOI: 10.1007/s00431-024-05622-3] [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: 12/27/2023] [Revised: 05/10/2024] [Accepted: 05/19/2024] [Indexed: 05/30/2024]
Abstract
The objective of this study was to assess the quality and consistency of recommendations in clinical practice guidelines (CPGs) and expert consensus on paediatric cow's milk protein allergy (CMPA) to serve as a foundation for future revisions and enhancements of clinical guidelines and consensus documents. We conducted a comprehensive literature search across several databases, including the Chinese Biomedical Literature Database (CBM), PubMed, Embase, Web of Science, UpToDate, ClinicalKey, DynaMed Plus and BMJ Best Practice. We spanned the search period from the inception of each database through October 1, 2023. We integrated subject headings (MeSH/Emtree) and keywords into the search strategy, used the search methodologies of existing literature and developed it in collaboration with a librarian. Two trained researchers independently conducted the literature screening and data extraction. We evaluated methodological quality and recommendations by using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and AGREE-Recommendations for Excellence (AGREE-REX) tools. Moreover, we compared and summarized key recommendations from high-quality CPGs. Our study included 27 CPGs and expert consensus documents on CMPA. Only four CPGs (14.8%) achieved a high-quality AGREE II rating. The four high-quality CPGs consistently provided recommendations for CMPA. The highest scoring domains for AGREE II were 'scope and purpose' (77 ± 12%) and 'clarity of presentation' (75 ± 22%). The lowest scoring domains were 'stakeholder involvement' (49 ± 21%), 'rigor of development' (34 ± 20%) and 'applicability' (12 ± 20%). Evaluation with AGREE-REX generally demonstrated low scores across its domains. Conclusion: Recommendations within high-quality CPGs for the paediatric CMPA showed fundamental consistency. Nevertheless, the methodology and recommendation content of CPGs and the expert consensus exhibited low quality, thus indicating a substantial scope for enhancement. Guideline developers should rigorously follow the AGREE II and AGREE-REX standards in creating CPGs or expert consensuses to guarantee their clinical efficacy in managing paediatric CMPA. What is Known: • The quality of clinical practice guidelines and expert consensus on paediatric cow's milk protein allergy (CMPA) remains uncertain. • There is a lack of clarity regarding the consistency of crucial recommendations for CMPA management. What is New: • Improving the methodological quality of guidelines and consensus on CMPA requires greater emphasis on stakeholder engagement, rigorous development processes, and practical applicability. • The recommendations from four high-quality guidelines align. However, addressing clinical applicability, integrating values and preferences, and ensuring actionable implementation are critical to improving the quality of all guidelines.
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Affiliation(s)
- Tengfei Li
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Qingyong Zheng
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Mingyue Zhang
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Yiyi Li
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
| | - Yongjia Zhou
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
| | - Caihua Xu
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Bowa Zhang
- School of Nursing, Gansu University of Chinese Medicine, Lanzhou, China
| | - Zewei Wang
- First Clinical College of Medicine, Lanzhou University, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.
| | - Li Zhou
- Department of Gastroenterology, Gansu Province Maternity and Child Health Hospital (Gansu Province Central Hospital), Lanzhou, China.
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Bosco A, Altea V, Beretta P, Cacace R, Fanos V, Dessì A. Metabolomics in Children Cow's Milk Protein Allergy: Possible Contribution from a System Biology Approach? CHILDREN (BASEL, SWITZERLAND) 2024; 11:562. [PMID: 38790557 PMCID: PMC11120097 DOI: 10.3390/children11050562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024]
Abstract
One of the most frequent triggers of food anaphylaxis in pediatric age but also among the most common, early, and complex causes of childhood food allergy is cow's milk protein allergy (CMPA). The diagnostic course and management of this allergy is defined in a complex clinical picture due to several factors. First of all, the epidemiological data are not uniform, mainly as a consequence of the diagnostic methodology used in the various studies and the different age ranges covered. In addition, there is the complexity of terminology, since although CMPA traditionally refers to immune-mediated reactions to cow's milk, it is a term encompassing numerous clinical features with different symptoms and the requirement for specific treatments. Moreover, the differential diagnosis with other very frequent diseases, especially in the first year of life, such as gastro-esophageal reflux disease or colic, is still complex. This can result in misdiagnosis and incorrect treatment, with harmful health consequences and significant economic repercussions. In this context, the combination of several omics sciences together, which have already proved useful in clarifying the allergenicity of cow's milk proteins with greater precision, could improve the diagnostic tests currently in use through the identification of new, more specific, and precise biomarkers that make it possible to improve diagnostic accuracy and predict the patient's response to the various available treatments for the recovery of tolerance.
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Affiliation(s)
| | | | | | | | - Vassilios Fanos
- Department of Surgical Sciences, University of Cagliari and Neonatal Intensive Care Unit, AOU Cagliari, 09124 Cagliari, Italy; (A.B.); (V.A.); (P.B.); (R.C.); (A.D.)
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3
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Hicks A, Fleischer D, Venter C. The future of cow's milk allergy - milk ladders in IgE-mediated food allergy. Front Nutr 2024; 11:1371772. [PMID: 38496796 PMCID: PMC10941844 DOI: 10.3389/fnut.2024.1371772] [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: 01/16/2024] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Cow's milk allergy (CMA) is one of the most common and complex presentations of allergy in early childhood. CMA can present as IgE and non-IgE mediated forms of food allergy. Non-IgE mediated CMA includes food protein-induced enterocolitis syndrome (FPIES), eosinophilic gastrointestinal disorders (EGIDs), and food protein-induced proctocolitis (FPIAP). There are recent guidelines addressing CMA diagnosis, management, and treatment. Each of these guidelines have their own strengths and limitations. To best manage CMA, individualized avoidance advice should be given. Cow's milk (CM) can be replaced in the diet by using hypoallergenic formulas or plant-based milk, depending on factors such as the child's age and their current food intake. Oral and epicutaneous immunotherapy is used to increase tolerance in children with CMA but is not without risk, and the long-term outcome of sustained unresponsiveness is still unclear. The allergenicity of CM proteins are affected differently by different forms of heating, leading to the use of baked milk or milk ladders in the management of CMA, most likely the most promising option for future management and treatment of CMA. Future management of children with CMA will also include discussion around the immunomodulatory potential of the child's dietary intake.
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Affiliation(s)
| | | | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
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Salvatore S, Folegatti A, Ferrigno C, Pensabene L, Agosti M, D'Auria E. To Diet or Not to Diet This Is the Question in Food-Protein-Induced Allergic Proctocolitis (FPIAP)-A Comprehensive Review of Current Recommendations. Nutrients 2024; 16:589. [PMID: 38474718 DOI: 10.3390/nu16050589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Food-protein-induced allergic proctocolitis (FPIAP) is an increasingly reported transient and benign form of colitis that occurs commonly in the first weeks of life in healthy breastfed or formula-fed infants. Distal colon mucosal inflammation is caused by a non-IgE immune reaction to food allergens, more commonly to cow's milk protein. Rectal bleeding possibly associated with mucus and loose stools is the clinical hallmark of FPIAP. To date, no specific biomarker is available, and investigations are reserved for severe cases. Disappearance of blood in the stool may occur within days or weeks from starting the maternal or infant elimination diet, and tolerance to the food allergen is typically acquired before one year of life in most patients. In some infants, no relapse of bleeding occurs when the presumed offending food is reassumed after a few weeks of the elimination diet. Many guidelines and expert consensus on cow's milk allergy have recently been published. However, the role of diet is still debated, and recommendations on the appropriateness and duration of allergen elimination in FPIAP are heterogeneous. This review summarizes and compares the different proposed nutritional management of infants suffering from FPIAP, highlighting the pros and cons according to the most recent literature data.
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Affiliation(s)
- Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, 21100 Varese, Italy
| | - Alice Folegatti
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, 21100 Varese, Italy
| | - Cristina Ferrigno
- Department of Pediatrics, Buzzi Children's Hospital, 20154 Milan, Italy
| | - Licia Pensabene
- Pediatric Unit, Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, 88100 Catanzaro, Italy
| | - Massimo Agosti
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, 21100 Varese, Italy
| | - Enza D'Auria
- Department of Pediatrics, Buzzi Children's Hospital, 20154 Milan, Italy
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Vandenplas Y, Broekaert I, Domellöf M, Indrio F, Lapillonne A, Pienar C, Ribes-Koninckx C, Shamir R, Szajewska H, Thapar N, Thomassen RA, Verduci E, West C. An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy. J Pediatr Gastroenterol Nutr 2024; 78:386-413. [PMID: 38374567 DOI: 10.1097/mpg.0000000000003897] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/25/2023] [Indexed: 07/27/2023]
Abstract
A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Flavia Indrio
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France
- CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Corina Pienar
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Gastroenterology and Hepatology & Instituto de Investigacion Sanitaria, La Fe University Hospital, Valencia, Spain
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rut Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Christina West
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Vandenplas Y, Meyer RM, Huysentruyt K. Food allergy: Prevention and treatment of Cow's milk allergy. Clin Nutr ESPEN 2024; 59:9-20. [PMID: 38220412 DOI: 10.1016/j.clnesp.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 01/16/2024]
Affiliation(s)
- Yvan Vandenplas
- Paediatric Gastroenterology, KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Rosan M Meyer
- Imperial College, London, United Kingdom; Winchester University, Winchester, United Kingdom
| | - Koen Huysentruyt
- Paediatric Gastroenterology, KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Darma A, Sumitro KR, Jo J, Sitorus N. Lactose Intolerance versus Cow's Milk Allergy in Infants: A Clinical Dilemma. Nutrients 2024; 16:414. [PMID: 38337698 PMCID: PMC10856892 DOI: 10.3390/nu16030414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/06/2024] [Accepted: 01/12/2024] [Indexed: 02/12/2024] Open
Abstract
Due to its very early introduction, cow's milk is one of the first foods that can cause adverse reactions in human beings. Lactose intolerance (LI) and cow's milk allergy (CMA) are the most common adverse reactions to cow's milk. While LI is due to insufficient small intestinal lactase activity and/or a large quantity of ingested lactose, CMA is an aberrant immune reaction to cow's milk proteins, particularly casein or β-lactoglobulin. However, the clinical manifestations of LI and CMA, particularly their gastrointestinal signs and symptoms, are very similar, which might lead to misdiagnosis or delayed diagnosis as well as nutritional risks due to inappropriate dietary interventions or unnecessary dietary restriction. Formula-fed infants with LI should be treated with formula with reduced or no lactose, while those with CMA should be treated with formula containing extensive hydrolyzed cow's milk protein or amino acids. This review is therefore written to assist clinicians to better understand the pathophysiologies of LI and CMA as well as to recognize the similarities and differences between clinical manifestations of LI and CMA.
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Affiliation(s)
- Andy Darma
- Department of Child Health, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia;
- Department of Child Health, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| | - Khadijah Rizky Sumitro
- Department of Child Health, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia;
- Department of Child Health, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| | - Juandy Jo
- Department of Biology, Faculty of Science and Technology, Universitas Pelita Harapan, Tangerang 15811, Indonesia;
- Mochtar Riady Institute for Nanotechnology, Tangerang 15811, Indonesia
| | - Nova Sitorus
- Danone Specialized Nutrition Indonesia, Jakarta 12940, Indonesia;
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Dziechciarz P, Stróżyk A, Horvath A, Cudowska B, Jedynak-Wąsowicz U, Mól N, Jarocka-Cyrta E, Zawadzka-Krajewska A, Krauze A. Nutritional status and feeding difficulties in children up to 2 years of age with cow's milk allergy. J Pediatr Gastroenterol Nutr 2024. [PMID: 38291802 DOI: 10.1002/jpn3.12139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND/OBJECTIVES To assess the nutritional status and incidence of feeding difficulties in Polish children up to 2 years of age with cow's milk allergy (CMA) on cow's milk proteins-free diet. METHODS A cross-sectional, multi-center study included children aged 6 months to 2 years with confirmed or suspected (without oral food challenge) diagnosis of CMA on the elimination diet for at least 1 month. The primary outcomes were an assessment of proportion of children with impaired nutritional status (with the weight for length and body mass index (BMI) z-score > 1 and <-1), and feeding difficulties according to the Montreal Children's Hospital Feeding Scale. Children with confirmed and suspected CMA were assessed separately. RESULTS A 144 children with confirmed CMA and 88 with suspected CMA were included (57 and 78% with multiple food allergies, respectively). Among children with confirmed CMA, one-third (35.5%) of participants had any nutritional status impairment regardless of definition. Among those, most of children had mild malnutrition (10.4 vs. 9%) and possible risk of overweight (11.1 vs. 9.7%; following respectively BMI for age and weight for length z-scores). Only 16.0% of children had feeding difficulties. Feeding difficulties was identified to be a risk factor for moderate malnutrition compared to children without feeding difficulties (odds ratio 10, 95% confidence interval: 4-27). CONCLUSIONS Mild malnutrition and possible risk of overweight are concern in children up to 2 years of age on cow's milk proteins-free diet. Feeding difficulties are less common, however, may affect the nutritional status.
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Affiliation(s)
- Piotr Dziechciarz
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Agata Stróżyk
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Andrea Horvath
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Beata Cudowska
- Department of Paediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | | | - Nina Mól
- Department of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Jarocka-Cyrta
- Department of Pediatrics, Gastroenterology, and Nutrition, Collegium Medicum, University of Warmia & Mazury, Olsztyn, Poland
| | - Anna Zawadzka-Krajewska
- Department of Pneumonology and Allergology for Children, Medical University of Warsaw, Warsaw, Poland
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Venter C, Vieira MC, Fleischer D. Tolerance development in non-IgE mediated food allergies: lessons from Brazil. J Pediatr (Rio J) 2024; 100:4-7. [PMID: 37858601 PMCID: PMC10751694 DOI: 10.1016/j.jped.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Affiliation(s)
- Carina Venter
- University of Colorado School of Medicine, Department of Pediatrics, Section of Allergy & Immunology, Colorado, USA; Children's Hospital Colorado, Colorado, USA.
| | - Mario C Vieira
- Hospital Pequeno Príncipe, Centro de Gastroenterologia Pediátrica, Curitiba, PR, Brazil
| | - David Fleischer
- University of Colorado School of Medicine, Department of Pediatrics, Section of Allergy & Immunology, Colorado, USA; Children's Hospital Colorado, Colorado, USA
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Vandenplas Y, Meyer R, Nowak-Wegrzyn A, Salvatore S, Venter C, Vieira MC. The Remaining Challenge to Diagnose and Manage Cow's Milk Allergy: An Opinion Paper to Daily Clinical Practice. Nutrients 2023; 15:4762. [PMID: 38004156 PMCID: PMC10675216 DOI: 10.3390/nu15224762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Guidelines and recommendations for the diagnosis and management of cow's milk allergy (CMA) in childhood are based on scientific review of the available evidence. While this approach is the most rigorous, guidelines may not fully address all scenarios encountered by clinicians. Many symptoms of CMA overlap with other common childhood illnesses and are subjectively reported by the caregivers of the infant, as is the interpretation of the dietary interventions. Additionally, many healthcare professionals and caregivers do not follow the recommendations to perform an oral food challenge or reintroduction of cow's milk after a diagnostic elimination diet because (1) the infant is doing well and (2) the carer's fear of symptoms relapsing with this procedure. As a result, CMA in infants may be either under-diagnosed leading to reduced quality of life for families or over-diagnosed, resulting in unnecessary long-term elimination diets and increasing the risk for nutritional deficiencies. This paper discusses some of these controversial topics, focusing on misdiagnosis and mismanagement in clinical practice. The lack of objective diagnostic criteria can hamper the diagnosis and management of CMA in daily practice.
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Affiliation(s)
- Yvan Vandenplas
- UZ Brussel, KidZ Health Castle, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
| | - 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
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children’s Hospital, New York, NY 10016, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Silvia Salvatore
- Department of Pediatrics, Hospital “F. Del Ponte”, University of Insubria, 21100 Varese, Italy;
| | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, University of Colorado, Aurora, CO 80045, USA
| | - Mario C. Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba 80250, Brazil;
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