Cow's milk allergy in children: adherence to a therapeutic elimination diet and reintroduction of milk into the diet

Factors affecting formula compliance of infants with IgE mediated cow's milk protein allergy during the pandemic

Introduction

Cow's milk protein allergy (CMPA) is the most commonly encountered food allergy in the world, usually seen in infants under the age of 2 years. This study aims to determine the factors including COVID-19 affecting formula compliance of CMPA patients.

Methods

This study is a prospective, observational study based on 10 different Paediatric Allergy-Immunology clinics in Turkey. Patients aged between 6 months and 2 years, who were followed up with IgE-mediated CMPA treatment or newly diagnosed and using breast milk and/or formula were included in the study. The sociodemographic characteristics of the patients, their symptoms, the treatments they received, and the effects of the COVID-19 pandemic on adherence to formula were evaluated with a questionnaire administered to the parents.

Results

The compliance rate for formula-based treatment was 30.8% (IQR: 28.3, SD: 21.86). The number of patients with a single and multiple food allergy was 127 (51.6%) and 71 (28.9%), respectively. Breastfeeding duration, daily amount of prescribed formula and addition of sweetener to the formula were found to reduce compliance (p = 0.010, p = 0.003, and p = 0.004, respectively). However, it was determined that the patient's height, weight, age at diagnosis, and age of formula onset did not have a significant effect on compliance.

Conclusion

It was found that the duration of breastfeeding, the increase in the daily amount of formula requirement, and the addition of sweeteners had adverse effects on formula compliance. There was no significant correlation between the formula adherence of CMPA patients and the pandemic.

Cow's milk allergy in infancy and later development of type 1 diabetes-nationwide case-cohort study

BAKGROUND

It is suggested that early intake of cow's milk could be a risk factor for type 1 diabetes (T1DM). Further, the different immunological background, gives a suggestion of an inverse relationship for the occurrence of these diseases. The aim of this study was to explore the association between cow's milk allergy (CMA) and the risk of T1DM in a register-based case-cohort study.

METHODS

Data were obtained from Finnish nationwide health registers. The study included all children born in Finland between January 01, 1986 and December 31, 2008 and diagnosed with T1DM before the age of 16 years (n = 7754). A 10% random sample from each birth year cohort was selected as a reference cohort (n = 137,798). T1DM, CMA, and asthma were defined based on valid special reimbursements for the costs of drugs/special formulas needed in the treatment of the diseases. Child's sex, birth decade, asthma, maternal diabetes and asthma, smoking during pregnancy, and previous deliveries were considered as confounding factors. Time-dependent, weighted Cox regression was applied for statistical analyses.

RESULTS

Children with CMA had an increased risk of developing T1DM in fully adjusted model (HR = 1.17; 95% CI 1.02-1.34), but the association was no longer observed when including the use of special infant formulas in the definition of CMA in the sensitivity analysis (HR = 1.11; 95% CI 0.92-1.32). CMA was associated with an increased risk of T1DM in children without asthma (HR = 1.27; 95%CI 1.10-1.47), but not in children with asthma (HR = 0.80; 95% CI 0.92-1.27).

CONCLUSION

Children with CMA may have an increased risk of T1DM.

Bone health assessment of food allergic children on restrictive diets: a practical guide

BACKGROUND

Food allergy in childhood is on the rise globally and is managed with avoidance diets; recent case reports of food allergic children with nutritional rickets in the literature highlight the importance of close monitoring of bone health in this population.

METHODS

There is no consensus as yet with regard to bone health evaluation in food allergic children; therefore, extensive literature search was performed and the existing evidence is presented, along with a relevant algorithm.

RESULTS

Children allergic to cow's milk protein or presenting with allergy in more than three food items, as well as patients with severe allergic phenotypes or comorbidities known to affect the skeleton, seem to be at risk of metabolic bone disorders. As a practical guide, suspicious cases can be investigated with basic bone profile, whereas more severe cases (persistent bone pain and fractures) may undergo advanced bone health assessment, with bone mineral density (BMD) and metabolic bone markers' evaluation. Of note, these diagnostic steps call for further studies in the field of food allergy, as they are not performed as a routine. Evidence is accumulating with regard to vitamin D deficiency, osteopenia and imbalanced bone metabolism in those food allergic children who show poor dietary compliance or have inadequate medical supervision.

CONCLUSIONS

Ensuring optimal bone accrual in a food allergic child is an important task for the clinician and requires close monitoring of the restrictive diet and prompt therapeutic intervention, in an effort to avoid rickets or osteopenia.

Cows' milk exclusion diet during infancy: Is there a long-term effect on children's eating behaviour and food preferences?

BACKGROUND

Dietary restriction during infancy may influence later eating behaviour. The aim of this study was to determine whether consuming a cows' milk exclusion (CME) diet during infancy affects eating habits in later childhood, once cows' milk has been reintroduced into the diet.

METHODS

Children were recruited from two large birth cohort studies in the UK. A small number of participants were recruited from allergy clinic. Two groups were recruited: an experimental group of children who had consumed a CME diet during infancy and a control group, who had consumed an unrestricted diet during infancy. Parents and children completed questionnaires regarding eating behaviour and food preferences.

RESULTS

In total, 101 children of mean age 11.5 years were recruited (28 CME and 73 controls). The CME group scored significantly higher on 'slowness of eating' and on the combined 'avoidant eating behaviour' construct (p < 0.01). The number of foods avoided and symptoms was associated with higher levels of avoidant eating behaviour (p < 0.05). The CME group rated liking for several dairy foods (butter, cream, chocolate, full fat milk and ice cream) significantly lower than the control group (p < 0.05), although there were no significant differences seen for any other category of food.

CONCLUSION

This study demonstrated that consuming a CME diet during infancy has persistent and long-term effects on eating habits and food preferences. To reduce future negative eating behaviours, children's exclusion diets need to be as varied as possible and reintroduction of cows' milk products closely monitored.

Monitoring the impact of cow's milk allergy on children and their families with the FLIP questionnaire--a six-month follow-up study

BACKGROUND

Many children with cow's milk allergy (CMA) develop tolerance, but, challenges in daily life may remain. Using the Food hypersensitivity famiLy ImPact questionnaire (FLIP), we sought to monitor changes in the impact of CMA over time.

METHODS

Families of children with CMA, who participated in the validation of the FLIP, were re-approached 6 months later for follow-up. Change in reported difficulties was assessed by paired sample t-test and mixed models, stratifying by outgrown vs. persistent CMA.

RESULTS

Impact on families with children who had outgrown CMA (n = 20) decreased in the FLIP's total score (p = 0.0001) and in two subscales; Health and Emotions (p = 0.0001) and Everyday Life (p = 0.0001). In contrast, no significant improvements were registered in nutritional concerns. Impact on the group with persistent CMA (n = 57) was unchanged at follow-up except for more impact on Everyday Life (p = 0.001). In the final analysis comparing longitudinal changes in the groups, the strongest differences were observed for the subscales Health & Emotions and Everyday Life; for the Nutrition subscale, the between-group changes also differed, but to lesser extent.

CONCLUSIONS

We have documented the varying impact of CMA on parents and children over time. Families who were still affected continued to experience impact in daily life. Despite development of tolerance, families who were no longer affected revealed continuing nutritional concerns. Follow-ups should be offered even after outgrown CMA to encourage progression to unrestricted diet, to prevent eating disorders and to promote healthy growth.

Diagnosis and management of food allergies: new and emerging options: a systematic review

It is reported that 6% of children and 3% of adults have food allergies, with studies suggesting increased prevalence worldwide over the last few decades. Despite this, our diagnostic capabilities and techniques for managing patients with food allergies remain limited. We have conducted a systematic review of literature published within the last 5 years on the diagnosis and management of food allergies. While the gold standard for diagnosis remains the double-blind, placebo-controlled food challenge, this assessment is resource intensive and impractical in most clinical situations. In an effort to reduce the need for the double-blind, placebo-controlled food challenge, several risk-stratifying tests are employed, namely skin prick testing, measurement of serum-specific immunoglobulin E levels, component testing, and open food challenges. Management of food allergies typically involves allergen avoidance and carrying an epinephrine autoinjector. Clinical research trials of oral immunotherapy for some foods, including peanut, milk, egg, and peach, are under way. While oral immunotherapy is promising, its readiness for clinical application is controversial. In this review, we assess the latest studies published on the above diagnostic and management modalities, as well as novel strategies in the diagnosis and management of food allergy.