Soy allergy in infants and children with IgE-associated cow's milk allergy

Escalation of soya cross-allergy in infants with cow's milk allergy

BACKGROUND

Cow's milk allergy (CMA) is a common condition in infants, requiring alternative protein sources in their diets. Soya milk has become a popular substitute, especially in developing countries where it is a more affordable option compared to expensive hypoallergenic feeds for infants with insufficient breast milk supply. However, recent observations have shown an increase in soya cross-allergic reactions among infants with CMA.

AIM

To determine how often infants diagnosed with CMA also had soya cross-allergy and to examine the symptoms and outcomes of these infants at 2 years of age.

METHODS

Data from two pediatric centers were analyzed, looking at clinical records of children under 2 years old diagnosed with CMA from August 2015 to July 2023, divided into two four-year periods.

RESULTS

The records of 432 infants with CMA were analyzed. In the first four-year period from August 2015 to July 2019, 142 infants were studied, with 27 (19%) found to have soya-protein allergy as well. In the second four-year period, a total of 290 infants were studied, and soya allergy was found in 136 babies (47%). This represents a significant increase (P < 0.0001) in cases of soya protein cross-allergy among infants with CMA. The most common symptoms observed were gastroesophageal reflux disorder (39%), followed by failure to thrive, bloody diarrhea, watery diarrhea, and constipation. At 2 years of age, these infants showed significant growth failure compared to infants with CMA only.

CONCLUSION

In conclusion, this study emphasizes the importance of being cautious when using soy protein in infants with cow's milk protein allergy, especially in areas where cost is a major concern.

Are We Meeting the Needs? A Systematic Review of Nutritional Gaps and Growth Outcomes in Children with Multiple Food Allergies

BACKGROUND/OBJECTIVES

Food allergies represent a growing public health challenge, showing an alarming increase in prevalence over the past few decades. Children with multiple food allergies face not only allergic reaction risks but also nutritional gaps, affecting diet, nutrition, and growth. This review summarizes the impact on nutrient intake and growth, highlighting key challenges and strategies to improve clinical care.

METHODS

The literature search was conducted using a structured search strategy in PubMed up to 31 January, using MeSH terms with Boolean operators (AND, OR) to combine searches (food hypersensitivity AND growth, food hypersensitivity AND nutrition, food hypersensitivity AND micronutrient, food hypersensitivity AND vitamin, food hypersensitivity AND trace element, and soy hypersensitivity) for human studies meeting pre-defined PICOS criteria that simultaneously assessed the reproducibility and validity.

RESULTS

Nearly 2000 studies were identified in the literature search, with 31 articles selected for full-text evaluation and 11 articles included in the final review. Dietary restrictions imposed by the need to avoid multiple allergens can lead to a reduced intake of essential nutrients, particularly proteins, calcium, iron, zinc, iodine, folate, vitamin B12, and vitamin D. Children with multiple FAs appear to be at an increased risk of impaired growth, as evidenced by the lower height-for-age, weight-for-age, head-circumference, and weight-for-length Z-scores compared to non-allergic peers.

CONCLUSIONS

Evidence from the studies reviewed suggests that children with multiple FAs may be at increased risk for growth impairments and nutritional inadequacies, especially where dietary management does not adequately compensate for nutrient losses, and highlights that tailored dietary counseling is crucial.

Growth, Safety and Tolerance in Infants Fed Rice Protein Hydrolysate Formula: The GRITO Randomised Controlled Trial

Background: Hydrolysed rice formula (HRF) is tolerated by >90% of children with cow's milk protein allergy (CMPA). However, concerns have been raised about potential suboptimal growth in infants fed HRF compared to those fed an extensively hydrolysed milk protein formula (eHF). Aims: To compare growth, safety and tolerance acquisition in infants with CMPA when fed HRF versus eHF. Methods: A multicentre prospective, randomised, double-blind, placebo-controlled food challenge trial was conducted with infants with CMPA. The infants received either HRF or eHF over a 12-month follow-up period. The primary outcome measure was the change from baseline over the study period in weight-for-length expressed as a Z-score. The secondary outcomes were other anthropometric measurements, tolerability and adverse events (AEs). Results: In total, 105 children were enrolled. The weight-for-length measurements were -0.01 (HRF) and -0.29 (eHF) at baseline and 0.29 and 0.05, respectively, at the last visit, with no significant between-group difference (p = 0.28; mixed-effects model). The Z-scores for other anthropometric variables indicated normal growth, with no significant between-group differences. In total, 29 potentially product-related AEs were reported (12 in the HRF group and 17 in the eHF group). A trend was observed toward a faster acquisition of tolerance in the HRF group (median age: 20.4 months) compared to the eHF group (16.3 months), but this was not statistically significant (p = 0.18). Conclusions: HRF demonstrated appropriate growth, acquisition of tolerance and a good safety profile in infants with CMPA, with no significant differences versus eHF. HRF could be considered as an appropriate option in the management of CMPA.

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update - XI - Milk supplement/replacement formulas for infants and toddlers with CMA - Systematic review

Background

Cow's milk allergy (CMA) is the most complex and common food allergy in infants. Elimination of cow's milk from the diet and replacement with a specialized formula for infants with cow's milk allergy who cannot be breastfed is an established approach to minimize the risk of severe allergic reactions while avoiding nutritional deficiencies. Given the availability of multiple options, such as extensively hydrolyzed cow's milk-based formula (eHF-CM), aminoacid formula (AAF), hydrolyzed rice formula (HRF), and soy formula (SF), there is some uncertainty regarding which formula might represent the most suitable choice with respect to health outcomes. The addition of probiotics to a specialized formula has also been proposed as a potential approach to possibly increase the benefit. We systematically reviewed specialized formulas for infants with CMA to inform the updated World Allergy Organization (WAO) DRACMA guidelines.

Objective

To systematically review and synthesize the available evidence about the use of specialized formulas for the management of individuals with CMA.

Methods

We searched from inception PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the websites of selected allergy organizations, for randomized and non-randomized trials of any language investigating specialized formulas with or without probiotics. We included all studies irrespective of the language of the original publication. The last search was conducted in January 2024. We synthesized the identified evidence quantitatively or narratively as appropriate and summarized it in the evidence profiles. We conducted this review following the PRISMA, Cochrane methods, and the GRADE approach.

Results

We identified 3558 records including 14 randomized trials and 7 observational studies. Very low certainty evidence suggested that in infants with IgE-mediated CMA, eHF-CM, compared with AAF, might have higher probability of outgrowing CMA (risk ratio (RR) 2.32; risk difference (RD) 25 more per 100), while showing potentially lower probability of severe vomiting (RR 0.12, 95% CI 0.02 to 0.88; RD 23 fewer per 100, 95% CI 3 to 26) and developing food protein-induced enterocolitis syndrome (FPIES) (RR 0.15, 95% CI 0.03 to 0.82; RD 34 fewer per 100, 95% CI 7 to 39). We also found, however, that eHF-CM might be inferior to AAF in supporting a physiological growth, with respect to both weight (-5.5% from baseline, 95%CI -9.5% to -1.5%) and length (-0.7 z-score change, 95%CI -1.15 to -0.25) (very low certainty). We found similar effects for eHF-CM, compared with AAF, also in non-IgE CMA. When compared with SF, eHF-CM might favor weight gain for IgE CMA infants (0.23 z-score change, 95%CI 0.01 to 0.45), and tolerance acquisition (RR 1.86, 95%CI 1.03 to 3.37; RD 27%, 95%CI 1%-74%) for non-IgE CMA (both at very low certainty of the evidence (CoE)). The comparison of eHF-CM vs. HRF, and HRF vs. SF, showed no difference in effect (very low certainty). For IgE CMA patients, low certainty evidence suggested that adding probiotics (L. rhamnosus GG, L. casei CRL431 and B. lactis Bb-12) might increase the probability of developing CMA tolerance (RR 2.47, 95%CI 1.03 to 5.93; RD 27%, 95%CI 1%-91%), and reduce the risk of severe wheezing (RR 0.12, 95%CI 0.02 to 0.95; RD -23%, 95%CI -8% to -0.4%). However, in non-IgE CMA infants, the addition of probiotics (L. rhamnosus GG) showed no significant effect, as supported by low to very low CoE.

Conclusions

Currently available studies comparing eHF-CM, AAF, HRF, and SF provide very low certainty evidence about their effects in infants with IgE-mediated and non-IgE-mediated CMA. Our review revealed several limitations in the current body of evidence, primarily arising from concerns related to the quality of studies, the limited size of the participant populations and most importantly the lack of diversity and standardization in the compared interventions. It is therefore imperative for future studies to be methodologically rigorous and investigate a broader spectrum of available interventions. We encourage clinicians and researchers to review current World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines for suggestions on how to use milk replacement formulas in clinical practice and what additional research would be the most beneficial.

Differential effects of heating modes on the immunogenic potential of soy-derived peptides released after in vitro infant digestion

During production of soy-based infant formula, soy protein undergoes heating processes. This study investigated the differential impact of heating modes on the immunogenic potential of peptides in soy protein digests. Wet or dry heating was applied, followed by in vitro gastrointestinal infant digestion. The released peptides were analyzed by LC-MS/MS. Bioinformatics tools were utilized to predict and identify potential linear B-cell and T-cell epitopes, as well as to explore cross-reactivity with other legumes. Subsequently, the peptide intensities of the same potential epitope across different experimental conditions were compared. As a result, we confirmed the previously observed enhancing effect of wet heating on infant digestion and inhibitory effect of dry heating. A total of 8,546 peptides were detected in the digests, and 6,684 peptides were with a score over 80. Among them, 29 potential T-cell epitopes and 27 potential B-cell epitopes were predicted. Cross-reactivity between soy and other legumes, including peanut, pea, chickpea, lentil, kidney bean, and lupine, was also detected. Overall, heating and digestion time could modulate the potential to trigger peptide-induced immune responses.

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

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.

Early Introduction of Novel and Less-Studied Food Allergens in the Plant-Based Era: Considerations for US and EU Infant Formula Regulations

Early life feeding practices may affect the long-term health of individuals, particularly in terms of the development of non-communicable diseases, such as metabolic and allergic diseases. Accumulating evidence suggests that the interplay of breastfeeding and/or formula feeding followed by the introduction of solids plays a role in the occurrence of non-communicable diseases both in the short and long term. International food allergy guidelines recommend that breastfeeding women do not need to avoid food allergens and do not recommend any infant formula for allergy prevention. Guidelines regarding solid food introduction for food allergy prevention recommend the introduction of well-cooked eggs and peanuts around 4-6 months of age, and not to delay the introduction of other food allergens. There is also an increasing trend to feed infants a plant-based or plant-forward diet and have access to infant formulas based on plant-based ingredients. The use of novel plant-based infant formulas raises a few questions reviewed in this paper: (1) Do fortified, plant-based infant formulas, compliant with US Food and Drug Administration (FDA) regulations and European Food Safety Authority (EFSA) (European) guidelines, support adequate infant growth? (2) Are plant-based infant formulas suitable for the management of cow's milk allergy? (3) Does feeding with novel, plant-based infant formulas increase the risk of food allergies to the food allergens they contain? (4) Does feeding infants plant-based food allergens in early life increase the risk of allergic and severe allergic reactions? The review of the literature indicated that (1) plant-based formulas supplemented with amino acids and micronutrients to comply with FDA regulations and EFSA guidelines, evaluated in sufficiently powered growth studies, can support adequate growth in infants; (2) currently available plant-based infant formulas are suitable for the management of CMA; (3) an early introduction and continuous intake of food allergens are more likely to prevent food allergies than to increase their risk; and (4) an early introduction of food allergens in young infants is safe.

ELISA Based Immunoreactivity Reduction of Soy Allergens through Thermal Processing

Allergens are proteins and are, therefore, likely to be denatured when subjected to thermal treatment. Traditional cooking has so far been able to reduce allergen sensitivity by around 70–90%. This study was aimed at evaluating the effect of a broad range of thermal treatments on the reduction of soy immunoreactivity (IR) in a 5% slurry using a sandwich ELISA technique. Cooking at 100 °C (10–60 min) and different thermal processing conditions, such as in commercial sterilization (with a process lethality (Fo) between 3 and 5 min) and selected severe thermal processing conditions (Fo > 5 and up to 23 min) were used in the study to evaluate their influence on allergen IR. Based on an IR comparison with an internal soy allergen standard, the allergen concentration in the untreated soy sample was calculated to be equivalent to 333 mg/kg (ppm). Cooking conditions only reduced the IR sensitivity to about 10 mg/kg (~1.5 log reductions), while the thermal processing treatments lowered the allergen IR up to 23 × 10−3 mg/kg (or 23 ppb) (>4 log reductions). FTIR analysis indicated significant changes in protein structure resulting from the thermal processing treatments, with a higher degree of allergen reduction corresponding with a higher value of random coil percentages. The influence of process severity on color and rheological properties was, however, minimal.

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.

Do Lipids Influence Gastrointestinal Processing: A Case Study of Major Soybean Allergen Gly m 4

Previously, we have demonstrated that Gly m 4, one of the major soybean allergens, could pass through the Caco-2 epithelial barrier and have proposed a mechanism of sensitization. However, it is not known yet whether Gly m 4 can reach the intestine in its intact form after digestion in stomach. In the present work, we studied an influence of various factors including lipids (fatty acids and lysolipids) on digestibility of Gly m 4. Using fluorescent and CD spectroscopies, we showed that Gly m 4 interacted with oleic acid and LPPG (lyso-palmitoyl phosphatidylglycerol), but its binding affinity greatly decreased under acidic conditions, probably due to the protein denaturation. The mimicking of gastric digestion revealed that Gly m 4 digestibility could be significantly reduced with the change of pH value and pepsin-to-allergen ratio, as well as by the presence of LPPG. We suggested that the protective effect of LPPG was unlikely associated with the allergen binding, but rather connected to the pepsin inhibition due to the lipid interaction with its catalytic site. As a result, we assumed that, under certain conditions, the intact Gly m 4 might be able to reach the human intestine and thereby could be responsible for allergic sensitization.

Peanut Can Be Used as a Reference Allergen for Hazard Characterization in Food Allergen Risk Management: A Rapid Evidence Assessment and Meta-Analysis

Regional and national legislation mandates the disclosure of “priority” allergens when present as an ingredient in foods, but this does not extend to the unintended presence of allergens due to shared production facilities. This has resulted in a proliferation of precautionary allergen (“may contain”) labels (PAL) that are frequently ignored by food-allergic consumers. Attempts have been made to improve allergen risk management to better inform the use of PAL, but a lack of consensus has led to variety of regulatory approaches and nonuniformity in the use of PAL by food businesses. One potential solution would be to establish internationally agreed “reference doses,” below which no PAL would be needed. However, if reference doses are to be used to inform the need for PAL, then it is essential to characterize the hazard associated with these low-level exposures. For peanut, there are now published data relating to over 3000 double-blind, placebo-controlled challenges in allergic individuals, but a similar level of evidence is lacking for other priority allergens. We present the results of a rapid evidence assessment and meta-analysis for the risk of anaphylaxis to a low-level allergen exposure for priority allergens. On the basis of this analysis, we propose that peanut can and should be considered an exemplar allergen for the hazard characterization at a low-level allergen exposure.

Protein profile of commercial soybean milks analyzed by label-free quantitative proteomics

The consumption of soy milk is increasing worldwide for its nutritional value and health benefits, however, its protein composition after commercialization is not well known. Technological and thermal treatments to which soy milk is subjected could affect the protein composition of the commercial products. This study compared the protein profile of 15 different commercial soy milks using a label-free quantitative proteomics approach. Proteins related to nutrient reservoir activity, endopeptidase inhibitor activity, lipid binding, and seed maturation contribute the most in terms of percentage mass. Their associated Gene Ontology terms are also enriched. Samples clustered into three groups based on their protein composition, with glycinins and beta-conglycinins being the most influential for determining the clustering. Amino acid composition estimated from the proteomics data also reflects the clustering of samples. Twenty allergenic proteins varying in abundance were identified, with Gly m 5 and Gly m 6 being the predominantly abundant allergens.

The effect of diet in infancy on asthma in young adults: the Merthyr Allergy Prevention Study

INTRODUCTION

Early infant diet might influence the risk of subsequent allergic disease.

METHODS

The Merthyr Allergy Prevention Study (MAPS) was a randomised controlled trial in infants at high risk of allergic disease. The trial determined whether a cow's milk exclusion diet for the first 4 months of life decreased the risk of allergic disease including asthma compared with a normal diet. A soya milk preparation was offered to those in the intervention group. A standardised questionnaire for allergic disease was completed at ages 1, 7, 15 and 23 years, with clinical assessment at 1, 7 and 23 years. The effect of the intervention on the risk of atopy, asthma and wheeze at age 23 years was determined.

FINDINGS

487 subjects entered the study; at age 23 years 299 completed the questionnaire, of which 119 attended clinical assessment. Subjects randomised to the intervention group had a significantly increased risk of atopy (adjusted OR 2.97, 95% CI 1.30 to 6.80; p=0.01) and asthma (OR 2.07, 95%CI 1.09 to 3.91; p=0.03) at age 23 years, but not wheeze (OR 1.43, 95%CI 0.87 to 2.37; p=0.16). Earlier exposure to cow's milk was associated with a decreased risk of wheeze and asthma at age 23 years, while earlier exposure to soya milk was associated with an increased risk of atopy and asthma.

INTERPRETATION

In infants at high risk of allergic disease, either cow's milk exclusion or early soya milk introduction for the first 4 months of life increases the risk of atopy, wheeze and asthma in adulthood.

Potential of Probiotic Frozen Blackcurrant Products: Consumer Preference, Physicochemical Characterization, and Cell Viability

Blackcurrant is a healthy, affordable, and traditionally gardened berry that, thus far, has been underused in food applications. From the consumers’ point of view, the acidic taste of blackcurrants is a challenge; therefore, these berries have mainly been utilized for sugary juice production. This research study aimed to develop a frozen vegan blackcurrant product with pleasant sensory properties and potential probiotic function. A candidate probiotic, Lactoplantibacillus plantarum Q823, was used in the manufacturing process. The physicochemical properties, nutritional composition, and consumer preference for the developed product were assessed, as was the viability of L. plantarum Q823 during storage time and in an in vitro gastrointestinal model. Consumers (n = 71) perceived the developed product to be pleasant. L. plantarum Q823 had high viability counts (log colony forming units (cfu) g⁻¹ 7.0 ± 0.38) in the final product, although the viability of L. plantarum Q823 during storage time needs to be enhanced to obtain a probiotic product. Thus, within an optimized formulation, blackcurrant berries represent a potential raw material for functional frozen food products.

Non-animal proteins as cutting-edge ingredients to reformulate animal-free foodstuffs: Present status and future perspectives

Consumer interest in protein rich diets is increasing, with more attention being paid to the protein source. Despite the occurrence of animal proteins in the human diet, non-animal proteins are gaining popularity around the world due to their health benefits, environmental sustainability, and ethical merit. These sources of protein qualify for vegan, vegetarian, and flexitarian diets. Non-animal proteins are versatile, derived mainly from cereals, vegetables, pulses, algae (seaweed and microalgae), fungi, and bacteria. This review's intent is to analyze the current and future direction of research and innovation in non-animal proteins, and to elucidate the extent (limitations and opportunities) of their applications in food and beverage industries. Prior knowledge provided relevant information on protein features (processing, structure, and techno-functionality) with particular focus on those derived from soy and wheat. In the current food landscape, beyond conventionally used plant sources, other plant proteins are gaining traction as alternative ingredients to formulate animal-free foodstuffs (e.g., meat alternatives, beverages, baked products, snack foods, and others). Microbial proteins derived from fungi and algae are also food ingredients of interest due to their high protein quantity and quality, however there is no commercial food application for bacterial protein yet. In the future, key points to consider are the importance of strain/variety selection, advances in extraction technologies, toxicity assessment, and how this source can be used to create food products for personalized nutrition.

Use of Soy-Based Formulas and Cow's Milk Allergy: Lights and Shadows

Soybean (Glycine max) is a species of legume native to East Asia and used in childhood diet for over 2,000 years in the East. Soy protein formulas have been available for almost a century. Nowadays, the increase in cow's milk allergy and vegetarian dietary preferences are driving consumers toward cow's milk alternatives. In this paper, we reviewed the nutritional composition of soy-based infant formula and discussed their possible use in pediatric age, mainly focusing on prevention and treatment of cow's milk allergy. Protein quality is determined by digestibility and amino acid content. Purified or concentrated vegetable proteins (e.g., soy protein and gluten) have high digestibility (>95%), similar to those of animal ones. For some intact vegetable products (e.g., whole cereals and pulses), protein digestibility is lower (80-90%). Food processing and heat treatment also influence protein digestibility. Considering these data, we tried to evaluate the possible use of soybean and derivatives in pediatric age, including the nutritional composition of soy formulas and the clinical indications for their use. Moreover, since plant-based beverages are being perceived as healthy by consumers and their use is growing on the market, we recommend that soy drink should not be used as a substitute for infant formulas or cow's milk in children younger than 24 months.

Design, quality, safety and efficacy of extensively hydrolyzed formula for management of cow's milk protein allergy: What are the challenges?

Cow's milk protein allergy (CMPA) is one of the most common food allergies in infancy. Clinical food allergy guidelines recommend an extensively hydrolyzed formula (EHF) as the first-line treatment in nonbreastfed infants with CMPA. Designing and commercializing EHF poses both technical and regulatory challenges. Each manufacturing step, from sourcing of raw materials to release of the final product, needs to be managed in accordance with comprehensive quality systems. To avoid cross-contamination via externally sourced ingredients, suppliers should be carefully selected based on quality requirements. Strict zoning of the manufacturing areas according to contamination risk and air flow control are effective strategies to prevent accidental allergen contamination. Furthermore, dedicated manufacturing lines for hypoallergenic products are used to prevent potential cross-contamination from other products produced on the same line. The enzymatic hydrolysis, heat treatment and ultrafiltration used are specific to each manufacturer. Consequently, EHF are a heterogenous group of products with differences in the molecular weight profile of peptides, content of residual immunogenic cow's milk allergens, and residual in-vitro allergenicity. These differences are likely to affect clinical efficacy and safety. As not all commercialized EHF products have undergone formal testing in the laboratory and clinical trials, there is a need to develop guidelines for minimum technical and regulatory requirements for EHF products, including validated assays for ongoing quality control. Clinical trials assessing new EHF products for their hypoallergenicity and ability to support normal growth remain the definitive proof of efficacy and safety in infants and young children with CMPA.

Standard and Specialized Infant Formulas in Europe: Making, Marketing, and Health Outcomes

Infant formulas are the only suitable substitute for human milk. The most common infant formulas are standard formulas based on cow's milk. In addition, there are formulas for infants showing signs and symptoms of intolerance and for clinical conditions such as allergy, prematurity, and gastrointestinal diseases. A comprehensive review of the literature was made to review the composition of standard and specialized infant formulas and analyze indications for use, real or presumed nutrition differences and properties, and impact on infant growth. A brief consideration on costs is outlined for each formula. Over the past few years, industrial production and advertising of infant formulas have increased. Human milk still remains the most complete source of nutrition for infants and should be continued according to the current recommendations. Few differences exist between infant formulas, both for the nutrition action and the macronutrient/micronutrient composition. Specialized infant formulas have limited indications for use and high costs. The role of the pediatrician is crucial in the management of infant nutrition, promotion of breastfeeding, and prescribing of specialized formulas only in specific clinical conditions.

Health issues and technological aspects of plant-based alternative milk

A growing number of consumers opt for plant-based milk substitutes for medical reasons, like cow's milk protein allergy (CMPA), lactose intolerance (LI), or as a lifestyle choice. Plant-based milk substitutes, or plant extracts, are water-soluble extracts of legumes, oilseeds, cereals or pseudocereals that resemble bovine milk in appearance. It is produced by reducing the size of the raw material, extracted in water and subsequently homogenized, being an alternative to cow's milk. They are considered cow's milk replacers due to similar chemical composition and can also be used as a substitute for direct use or in some animal milk-based preparations. On the other hand, these substitutes exhibit different sensory characteristics, stability and nutritional composition from cow's milk. They are manufactured by extracting the raw material in water, separating the liquid, and formulating the final product. Others process like homogenization and thermal treatments are indispensable to improve the suspension and microbiological stabilities of the final product so that can be consumed. However new and advanced non-thermal processing technologies such as ultra-high pressure homogenization and pulsed electric field processing are being researched for tackling the problems related to increase of shelf life, emulsion stability, nutritional completeness and sensory acceptability without the use of high temperatures. Some pre-treatments such as peeling, bleaching or soaking can be performed on the raw material in order to improve the final product. The nutritional properties are influenced by the plant source, processing, and fortification. The addition of other ingredients as sugar, oil and flavorings is done to the plant-based milk substitute to make them more palatable and be more acceptable to consumers. Thus, the aim is to review the main reasons for the consumption of plant-based milk substitute as well as the raw materials used and the technological aspects of its production.

Impact of soy consumption on human health: integrative review

Abstract Soy consumption is a millenary habit of populations of the eastern world and has recently increased in the western world. The risks and benefits of this practice have been extensively studied, with a current fundamental need of integration of available information. The aim of this study was to carry out an integrative review on this topic, in order to consolidate the available information. Based on the main question: “What is the impact of soy consumption on human health?”, were reviewed publications classified as original articles and reviews published from 1998 to 2020 in the databases Scopus, PubMed, SciELO, Web of Science, and Cochrane Library. A total of 97 studies were selected. In the present review were described the general impact of soy on human health and its protein quality, the effects of early exposure using soy formulas, and the effects of soy consumption on breast cancer, endometrial and ovarian cancer, prostate cancer, gastrointestinal cancer, cardiovascular disease, glucose metabolism and type 2 diabetes, obesity, reproductive health, menopause, female and male osteoporosis, microbiota, immunity and immunomodulation, thyroid function, attention-deficit hyperactivity disorder, and renal function.

Combining 2-DE immunoblots and mass spectrometry to identify putative soybean (Glycine max) allergens

Soybean is recognized as a commonly allergenic food, but the identity of important allergens is not well studied. Recently, some global regulatory agencies started requiring quantitative analysis of individual allergens, including unproven allergens, as part of the risk assessment for genetically engineered (GE) soybeans. We sought to identify soybean proteins that bind IgE from any of 10 individual soybean-sensitized subjects. Soybean IgE binding proteins were identified by 2-DE immunoblots using sera from four soy-allergic and plasma from six soy-sensitized human subjects. Corresponding spots were excised from stained gels, digested, and analyzed using a quadrupole TOF Synapt G2-S tandem mass spectrometer. Results showed the major IgE binding proteins were subunits of either β-conglycinin (Gly m 5) or glycinin (Gly m 6). Soybean Kunitz trypsin inhibitor (SKTI) was a significant IgE binding protein for four subjects. Soybean agglutinin, seed biotinylated protein (SBP) of 65 kDa, late embryogenesis protein (LEP), and sucrose-binding protein were identified as IgE binding only for soy-sensitized subjects. We conclude that the major soybean allergens are isoforms of Gly m 5, Gly m 6, and possibly SKTI and that requirements for quantitative measurement of proteins that are not clear allergens is not relevant to safety.

Nutritional management of cow's milk allergy in children: An update

Cow's milk is one of the most common foods responsible for allergic reactions in children. Cow's milk allergy (CMA) involves immunoglobulin E (IgE)- and non-IgE-mediated reactions, the latter being both variable and nonspecific. Guidelines thus emphasize the need for physicians to recognize the specific syndromes of CMA and to respect strict diagnostic modalities. Whatever the clinical pattern of CMA, the mainstay of treatment is the elimination from the diet of cow's milk proteins. The challenge is that both the disease and the elimination diet may result in insufficient height and weight gain and bone mineralization. If, during CMA, the mother is not able or willing to breastfeed, the child must be fed a formula adapted to CMA dietary management, during infancy and later, if the disease persists. This type of formula must be adequate in terms of allergic efficacy and nutritional safety. In older children, when CMA persists, the use of cow's milk baked or heated at a sufficient temperature, frequently tolerated by children with CMA, may help alleviate the stringency of the elimination diet. Guidance on the implementation of the elimination diet by qualified healthcare professionals is always necessary. This guidance should also include advice to ensure adequate bone growth, especially relating to calcium intake. Specific attention should be given to children presenting with several risk factors for weak bone mineral density, i.e., multiple food allergies, vitamin D deficiency, poor sun exposure, steroid use, or severe eczema. When CMA is outgrown, a prolonged elimination diet may negatively impact the quality of the diet over the long term.

Soy, Soy Foods and Their Role in Vegetarian Diets

Soy is a basic food ingredient of traditional Asian cuisine used for thousands of years. In Western countries, soybeans have been introduced about a hundred years ago and recently they are mainly used for surrogate foods production. Soy and soy foods are common nutritional solutions for vegetarians, due to their high protein content and versatility in the production of meat analogues and milk substitutes. However, there are some doubts about the potential effects on health, such as the effectiveness on cardiovascular risk reduction or, conversely, on the possible disruption of thyroid function and sexual hormones. The soy components that have stimulated the most research interest are isoflavones, which are polyphenols with estrogenic properties highly contained in soybeans. In this review, we discuss the characteristics of soy and soy foods, focusing on their nutrient content, including phytoestrogens and other bioactive substances that are noteworthy for vegetarians, the largest soy consumers in the Western countries. The safety of use will also be discussed, given the growing trend in adoption of vegetarian styles and the new soy-based foods availability.

Development of novel quinoa-based yoghurt fermented with dextran producer Weissella cibaria MG1

The aim of this study was to develop a novel beverage fermented with Weissella cibaria MG1 based on aqueous extracts of wholemeal quinoa flour. The protein digestibility of quinoa based-milk was improved by applying complex proteolytic enzymes able to increase protein solubility by 54.58%. The growth and fermentation characteristics of Weissella cibaria MG1, including EPS production at the end of fermentation, were investigated. Fermented wholemeal quinoa milk using MG1 showed high viable cell counts (>10⁹cfu/ml), a pH of 5.16, and significantly higher water holding capacity (WHC, 100%), viscosity (0.57mPas) and exopolysaccharide (EPS) amount (40mg/l) than the chemical acidified control. High EPS (dextran) concentration in quinoa milk caused earlier aggregation because more EPS occupy more space, and the chenopodin were forced to interact with each other. Microstructure observation indicated that the network structures of EPS-protein improve the texture of fermented quinoa milk. Overall, Weissella cibaria MG1 showed satisfactory technology properties and great potential for further possible application in the development of high viscosity fermented quinoa milk.

Three-dimensional structure of Gly m 5 (β-conglycinin) plays an important role in its stability and overall allergenicity

To date, there is insufficient knowledge regarding the relationship of the allegenicity and the three-dimensional structure of Gly m 5 (β-conglycinin), a major allergen in soybean. In the present study, allergen Gly m 5 was demonstrated to generate three major digestion-resistant fragments when it was subjected to in vitro digestion. The largest fragment corresponded to the main body of the monomer and two smaller fragments corresponded to the main bodies of two modules of the monomer. Two major protease cleavage sites were located in the regions near to the connection between two modules. Coincidentally, the major digestion-resistant fragments were demonstrated to contain intact IgE epitopes and be capable to induce basophil histamine release in Gly m 5 sensitised piglets, indicating that the three-dimensional structure of Gly m 5 afforded the molecule some protection from complete degradation into small peptides and amino acids, and contributed to its overall allergenicity.

Proteins and bioactive peptides from donkey milk: The molecular basis for its reduced allergenic properties

The legendary therapeutics properties of donkey milk have recently been supported by many clinical trials who have clearly demonstrated that, even if with adequate lipid integration, it may represent a valid natural substitute of cow milk for feeding allergic children. During the last decade many investigations by MS-based methods have been performed in order to obtain a better knowledge of donkey milk proteins. The knowledge about the primary structure of donkey milk proteins now may provide the basis for a more accurate comprehension of its potential benefits for human nutrition. In this aspect, experimental data today available clearly demonstrate that donkey milk proteins (especially casein components) are more closely related with the human homologues rather than cow counterparts. Moreover, the low allergenic properties of donkey milk with respect to cow one seem to be related to the low total protein content, the low ratio of caseins to whey fraction, and finally to the presence in almost all bovine IgE-binding linear epitopes of multiple amino acid differences with respect to the corresponding regions of donkey milk counterparts.

A two-step enzymatic modification method to reduce immuno-reactivity of milk proteins

A two-step enzymatic approach to reduce immuno-reactivity of whey protein isolate and casein has been studied. The method involves partial hydrolysis of proteins with proteases, followed by repolymerization with microbial transglutaminase. Whey protein isolate partially hydrolyzed with chymotrypsin, trypsin, or thermolysin retained about 80%, 30%, and 20% of the original immuno-reactivity, respectively. Upon repolymerization the immuno-reactivity decreased to 45%, 35%, and 5%, respectively. The immuno-reactivity of hydrolyzed and repolymerized casein was negligible compared to native casein. The repolymerized products were partially resistant to in vitro digestion. Peptides released during digestion of repolymerized thermolysin-whey protein hydrolysate had less than 5% immuno-reactivity, whereas those of whey protein control exhibited a sinusoidal immuno-reactivity ranging from 5 to 20%. Peptides released during digestion of repolymerized thermolysin-casein hydrolysates had no immuno-reactivity. These results indicated that it is possible to produce hypoallergenic milk protein products using the two-step enzymatic modification method involving thermolysin and transglutaminase.

Past, present and future: The strength of plant-based dairy substitutes based on gluten-free raw materials

Plant-based foods are gaining popularity and the market is developing fast. This trend is based on several factors, like the change of lifestyle, interest in alternative diets, and the increasing awareness about sustainable production of food and especially proteins. Plant-based dairy substitutes can serve as an option to traditional food products, meeting many of these interests. However, the market is in its infancy and needs to progress. Trends show, that the market will change from being focused on mainly soya, almond and rice-based products, due to their unsustainable farming, and nutritional concerns, like genetic modification and low protein content. The market is likely to shift towards alternative plants to meet consumers' needs and desire for healthy, flavourful and intriguing products. In this regard, the aspect of allergy-free, like gluten-free products gain in importance. Research studies are approaching the nutritional quality of plant-based dairy substitutes, such as improving the protein quality and glycaemic properties. Furthermore, the application of these products or plant proteins as functional ingredients or substitutes for cow's milk in dairy products like cheese and yoghurt are disseminated. However, there is still a need for much more diversified studies in order to overcome stability, textural, nutritional and sensory problems.

Evaluation of Physicochemical and Glycaemic Properties of Commercial Plant-Based Milk Substitutes

The market for plant-based dairy-type products is growing as consumers replace bovine milk in their diet, for medical reasons or as a lifestyle choice. A screening of 17 different commercial plant-based milk substitutes based on different cereals, nuts and legumes was performed, including the evaluation of physicochemical and glycaemic properties. Half of the analysed samples had low or no protein contents (<0.5 %). Only samples based on soya showed considerable high protein contents, matching the value of cow's milk (3.7 %). An in-vitro method was used to predict the glycaemic index. In general, the glycaemic index values ranged from 47 for bovine milk to 64 (almond-based) and up to 100 for rice-based samples. Most of the plant-based milk substitutes were highly unstable with separation rates up to 54.39 %/h. This study demonstrated that nutritional and physicochemical properties of plant-based milk substitutes are strongly dependent on the plant source, processing and fortification. Most products showed low nutritional qualities. Therefore, consumer awareness is important when plant-based milk substitutes are used as an alternative to cow's milk in the diet.

Amino acid formula as a new strategy for diagnosing cow's milk allergy in infants: is it cost-effective?

AIMS

To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow's milk allergy (CMA).

MATERIALS AND METHODS

This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed.

RESULTS

The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation.

LIMITATIONS

In the absence of information in the literature, some premises were defined by a panel of specialists.

CONCLUSIONS

The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.

What's in the Bottle? A Review of Infant Formulas

Infant formulas are designed to be a substitute for breast milk. Since they are sole source of nutrition for growing and developing infants, they are highly regulated by the government. All ingredients in infant formulas must be considered "generally recognized as safe." Manufacturers are continually modifying their products to make them more like breast milk. Functional ingredients added to infant formula include long-chain polyunsaturated fatty acids, nucleotides, prebiotics, and probiotics. The most common breast milk substitutes are standard cow's milk-based term infant formulas, which include subcategories of organic and breast milk supplementation, and come in standard dilutions of 19 or 20 calories per ounce. In addition to standard cow's milk-based term infant formulas, there is a line of term infant formulas marketed for signs and symptoms of intolerance. These products include modifications in lactose content, partially hydrolyzed protein, added probiotics, or added rice starch. There are also specialized formulas for medical conditions such as prematurity, gastrointestinal disorders, allergy, disorders of fat metabolism, and renal insufficiency. Infants on specialty formulas should be monitored closely by medical professionals. Formulas come in ready-to-feed, liquid concentrate, and powder forms. Each offers advantages and disadvantages. Each step in the formula mixing process or each manipulation required for the feeding is another opportunity to introduce bacteria to the formula. There are guidelines for preparing formula in institutions. Standard dilution and mixing instructions are different for each formula, so individual recipes are needed. Caregivers should also be educated on proper hygiene when preparing formula at home.

Infant Formulas for Food Allergy Treatment and Prevention

The number of infant formulas intended for food allergy treatment or prevention has been increasing. Some products fulfill the criteria for hypoallergenicity, such as extensively hydrolyzed protein (casein or whey) and synthesized amino acid formulas (elemental diet). Numerous partially hydrolyzed formulas have been derived from bovine milk, soybean, and rice. They are not hypoallergenic and are not recommended for children allergic to the parent protein, yet certain preparations have shown efficacy for allergy prevention. Soybean-derived preparations, although not hypoallergenic, have been tolerated by a majority of children allergic to bovine milk. Studies on the addition of probiotics or prebiotics to infant formulas have shown inconsistent findings. Numerous hypoallergenic formulas or milk substitutes are available for pediatricians to choose for children with food allergy. Caution is needed in prescribing formulas that are erroneously marketed as hypoallergenic.

[Nutritional implications of elimination diets]

BACKGROUND

The backbone of food allergy treatment is the restriction of causative foods. These interventions have shown that children who restrict the consumption of basic foods have a higher risk of malnutrition. The aim of the study was to identify the nutritional status of patients with elimination diet, characterizing their anthropometric indexes and identifying the percentage of patients in the group with true food allergies.

METHODS

A cross-sectional study was carried out from January to October 2014 at the Hospital Infantil de Mexico Federico Gomez. Patients 1 to 11 years of age with a history of elimination of at least one of five foods (eggs, milk, wheat, corn, soybeans) for a minimum of 6 months were included. Full nutritional assessment was performed by comparing the anthropometric indexes to z score for age. Data analysis used descriptive statistics. Kruskal-Wallis and Spearman correlation were performed.

RESULTS

The most frequent eliminated foods were milk, soy, eggs, corn, and wheat. Comparing the number of foods eliminated with different anthropometric indexes, with a greater amount of eliminated food, the z-score of weight/age (W/A), height/age (H/A) and weight/height (W/H) were lower and the most affected index was fat reserve. Only in 5% of children was food allergy confirmed.

CONCLUSIONS

The study confirms the need for nutrition counseling for patients who have elimination diets and overdiagnosis of food allergy.

A comprehensive review of sensitization and allergy to soy-based products

Since 1943, cases of sensitization or allergy to soy-based formulas (SBFs) have been described without any consensus on their real prevalence. We identified the adjusted prevalence of IgE-mediated soy allergies in children and performed a secondary analysis of the impact of age (less than and more than 6 months). We performed a systematic review with meta-analysis of studies published from 1909 to 2013 in PubMed, Embase, LILACS, ARTEMISA, Cochrane, Bandolier, DARE and the GRADE system for grading quality. Results are presented in tables and graphs using a forest plot. The 40 studies identified established weighted prevalence of soy allergies of 0 to 0.5 % (0.27) for the general population, 0.4 to 3.1 % (1.9) for the referred population, and 0 to 12.9 % (2.7) for allergic children. Prevalence of sensitization after the use of SBFs is 8.7 and 8.8 %, depending on the method used. The prevalence of allergies to soy and IgE sensitization to the use of SBFs is less than reported. Not enough evidence exists to show a higher risk of allergy in infants younger than 6 months. The concern about soy allergy is no reason to postpone the use of SBFs in IgE-mediated cow's milk allergy infants until the age of 6 months.

BSACI guideline for the diagnosis and management of cow's milk allergy

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.

An extensively hydrolysed rice protein-based formula in the management of infants with cow's milk protein allergy: preliminary results after 1 month

BACKGROUND

Guidelines recommend extensively hydrolysed cow's milk protein formulas (eHF) in the treatment of infants diagnosed with cow's milk protein allergy (CMPA). Extensively hydrolysed rice protein infant formulas (eRHFs) have recently become available, and could offer a valid alternative.

METHODS

A prospective trial was performed to evaluate the clinical tolerance of a new eRHF in infants with a confirmed CMPA. Patients were followed for 1 month. Clinical tolerance of the eRHF was evaluated with a symptom-based score (SBS) and growth (weight and length) was monitored.

RESULTS

Thirty-nine infants (mean age 3.4 months, range 0.5-6 months) diagnosed with CMPA were enrolled. All infants tolerated the eRHF and experienced a normal growth.

CONCLUSIONS

In accordance with current guidelines, this eRHF is tolerated by more than 90% of children with proven CMPA with a 95% CI, and is an adequate alternative to cow's milk-based eHF.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01998074.

Cross-reactivity between the soybean protein p34 and bovine caseins

Purpose

Soy-based formulas are widely used as dairy substitutes to treat milk allergy patients. However, reactions to soy have been reported in a small proportion of patients with IgE-mediated milk allergies. The aim of this work was to explore whether P34, a mayor soybean allergen, is involved in this cross-reactivity.

Methods

In vitro recognition of P34 was evaluated by immunoblotting, competitive ELISA and basophil activation tests (BAT) using sera from allergic patients. In vivo cross-reactivity was examined using an IgE-mediated milk allergy mouse model.

Results

P34 was recognized by IgE antibodies from the sera of milk allergic patients, casein-specific monoclonal antibodies, and sera from milk-allergic mice. Spleen cells from sensitized mice incubated with milk, soy or P34 secreted IL-5 and IL-13, while IFN-γ remained unchanged. In addition, the cutaneous test was positive with cow's milk proteins (CMP) and P34 in the milk allergy mouse model. Moreover, milk-sensitized mice developed immediate symptoms following sublingual exposure to P34.

Conclusions

Our results demonstrate that P34 shares epitopes with bovine casein, which is responsible for inducing hypersensitivity symptoms in milk allergic mice. This is the first report of the in vivo cross-allergenicity of P34.