The step-down approach in children with cow's milk allergy: Results of a randomized controlled trial

Long term impact of formula choice in children with cow milk protein allergy: 6-year follow-up of the Atopic March Cohort Study

BACKGROUND AND AIMS

Cow's milk protein allergy (CMPA) is a significant health issue in the pediatric age, carrying lifelong health implications. To compare the impact of different formulas on the occurrence of other atopic manifestations (AMs), autoimmune disorders (ADs) and the time of immune tolerance acquisition in a population of children with immunoglobulin E (IgE)-mediated cow CMPA.

METHODS

In a 72-month prospective cohort study the occurrence of other AMs (i.e., eczema, urticaria, asthma, and rhinoconjunctivitis), ADs (i.e., celiac disease, thyroiditis, type 1 diabetes, inflammatory bowel diseases, idiopathic juvenile arthritis) and the time of immune tolerance acquisition were comparatively evaluated in IgE-mediated CMPA children treated with different formulas: extensively hydrolyzed casein formula containing the probiotic L. rhamnosus G (EHCF + LGG), rice hydrolyzed formula (RHF), soy formula (SF), extensively hydrolyzed whey formula (EHWF), or amino-acid based formula (AAF).

RESULTS

313 subjects were evaluated: EHCF + LGG (n = 64), RHF(n = 62), SF(n = 63), EHWF(n = 60) and AAF (n = 64). The incidence of AMs was: 0.30(Bonferroni-corrected 95%CI 0.15 to 0.44) for EHCF + LGG cohort, 0.68 (0.52-0.83) for RHF cohort, 0.73 (0.59-0.87) for SF cohort, 0.70 (0.55-0.85) for EHWF cohort and 0.83 (0.71-0.95) for AAF cohort. The corresponding risk ratios are 2.28 (1.51-3.45) for RHF vs. EHCF + LGG (p < 0.001), 2.46 (1.64-3.69) for SF vs. EHCF + LGG (p < 0.001), 2.36 (1.56-3.56) for EHWF vs. EHCF + LGG (p < 0.001), and 2.79 (1.88-4.13) for AAF vs. EHCF + LGG (p < 0.001). The 72-month immune tolerance acquisition rate was higher in the EHCF + LGG cohort. The incidence of celiac disease was 2/313 (0.006, binomial exact 95%CI 0.0007 to 0.023). No cases of other ADs were reported.

CONCLUSION

The dietary treatment with EHCF + LGG is associated with lower incidence of AMs and higher rate of immune tolerance acquisition in children with CMPA.

The Burden of Cow's Milk Protein Allergy in the Pediatric Age: A Systematic Review of Costs and Challenges

Background. Cow's Milk Protein Allergy (CMPA) is a prevalent pediatric food allergy affecting 2-5% of infants globally. CMPA presents significant clinical and economic challenges, requiring specialized diagnostic procedures, dietary management with hypoallergenic formulas, and multidisciplinary care. The financial burden on families and healthcare systems includes direct costs (e.g., diagnostic tests, medical consultations, and formula expenses), indirect costs (e.g., caregiver absenteeism and productivity loss), and intangible costs (e.g., psychological distress and impaired quality of life). Economic disparities further exacerbate these challenges, particularly in low-resource settings where access to specialized care is limited. Methods. A systematic review was conducted following PRISMA guidelines using PubMed, CINAHL, Scopus, and Cochrane databases to identify studies on the economic and psychosocial burden of CMPA. Studies published between 2010 and 2024 were analyzed. From an initial search of 11,565 articles, 802 duplicates were removed, leaving 10,763 articles for title and abstract screening. Twenty full-text articles meeting the inclusion criteria were included in the final analysis. Thematic categories focused on direct, indirect, and intangible costs, with findings synthesized to highlight global disparities and policy gaps. Results. CMPA management imposes substantial economic burdens, with hypoallergenic formulas alone accounting for up to 15% of household income in some regions. Indirect costs, including lost workdays and additional childcare expenses, further strain families. Intangible costs, such as heightened caregiver anxiety and reduced social participation, are significant yet frequently overlooked. Healthcare system disparities, particularly regarding insurance coverage for diagnostic tests and therapeutic formulas, contribute to financial inequities. The use of extensively hydrolyzed casein formulas with probiotics has demonstrated cost-effectiveness in promoting immune tolerance while reducing healthcare utilization. Conclusions. Addressing the economic impact of CMPA would benefit from standardized cost assessment frameworks and equitable access to cost-effective therapeutic options. Further analysis of reimbursement policies across diverse healthcare systems may provide insights into optimizing support for essential treatments. Integrating clinical and economic strategies can alleviate the burden on affected families and optimize healthcare resource allocation. Future research should prioritize longitudinal analyses and cross-regional comparisons to guide sustainable and equitable management strategies.

Human milk oligosaccharides and milk fat globule membrane reduce allergic reactions in mice through the modulation of gut microbiota and metabolic functions

Human milk oligosaccharides (HMOs) and the milk fat globule membrane (MFGM) represent novel treatments for cow's milk allergy (CMA). They exhibit the beneficial attribute of diminishing nutrient damage when compared to conventional enzymatic digestion of milk proteins. However, the effects and mechanisms underlying the synergistic interaction between HMOs and the MFGM in allergy treatment remain unclear. Consequently, this study was undertaken to assess the protective properties of HMOs and the MFGM against CMA and to elucidate their potential mechanisms in a mouse model of β-lactoglobulin (BLG)-induced allergy. The findings demonstrated that HMOs and the MFGM could significantly reduce the allergy score and splenic index, and they diminished the levels of inflammatory mediators (total immunoglobulin E (IgE), specific IgE, histamine, and mMCP-1), while concurrently bolstering tight junctions (ZO-1, claudin-1, and occludin), and reducing intestinal permeability. Notably, HMOs and the MFGM exhibited optimal synergy. In addition, HMOs and the MFGM synergistically mitigated the immune response to Th2 overactivity in allergy by the promotion of Th1 and Treg cell responses, thereby suppressing the levels of inflammatory cytokines IL-4 and IL-5. Analysis of the gut microbiota and its metabolic activities revealed that HMOs and the MFGM increased the abundance of Lactobacillus and Butyricicoccus, leading to higher production of butyrate. Furthermore, these beneficial bacteria and the resultant butyrate also contributed to the suppression of allergy-associated bacterial populations such as Desulfovibrio and Rikenellaceae. In summary, HMOs and the MFGM acted in synergy to modulate inflammatory responses and ameliorate barrier damage, contributing to the mitigation of CMA, a process potentially linked to gut microbiota dynamics and the resultant butyrate metabolism. This effect may be related to the gut microbiota and its metabolic production of butyrate.

Evolutive Study of Dietary Aspects and Intestinal Microbiota of Pediatric Cohort with Cow's Milk Protein Allergy

BACKGROUND

One of the most common food allergies in the pediatric population is allergy to cow's milk protein (CMPA). Treatment consists of avoiding cow's milk proteins in lactating mothers and/or using therapeutic formulas based on hydrolysates or vegetable formulas. In infants with CMPA at diagnosis, a different gut microbial profile has been found compared to healthy children, with a reduction in beneficial bacteria. The aim of this study was to evaluate changes in the gut microbiota profile and its metabolites, dietary patterns and anthropometric variables in a pediatric cohort with CMPA after six months on a restrictive diet compared to healthy controls.

METHODS

In total, 21 patients diagnosed with CMPA and a control group of 24 healthy infants participated in this study. The fecal microbiota of all participants were investigated by metataxonomic analysis of 16S rDNA amplicons, and fecal short-chain fatty acids were measured by gas chromatography. Epidemiological assessment and dietary questionnaires were carried out for both groups.

RESULTS

Regarding growth, no significant differences were found, but differences in dietary intake of some macro- and micronutrients were observed. Patients who were breastfed at six months had higher bifidobacteria and lipid intakes than patients fed with hydrolyzed formulas.

CONCLUSIONS

Although the growth of CMPA infants fed with therapeutic formula is similar to breastfed CMPA infants, there are differences in microbiota composition and macronutrient intake that underline the importance of continued breastfeeding in CMPA cases.

The journey toward disease modification in cow milk protein allergy

Cow milk protein allergy (CMPA) is one of the most common food allergies in the pediatric age worldwide. Prevalence, persistence, and severity of this condition are on the rise, with a negative impact on the health-related quality of life of the patients and families and on the costs related to its management. Another relevant issue is that CMPA in early life may be the first stage of the "allergic march," leading to the occurrence of other atopic manifestations later in life, especially asthma, atopic eczema, urticaria, and rhinoconjunctivitis. Thus, "disease modification" options that are able to modulate the disease course of pediatric patients affected by CMPA would be very welcomed by affected families and healthcare systems. In this review, we report the most relevant progress on this topic.

Oral Immunotherapy With Extensively Hydrolyzed Milk for a 12-Year-Old Child With Persistent, Severe Cow's Milk Allergy

A 12-year-old girl with severe cow's milk allergy (CMA) was able to safely consume 300 mL of unhydrolyzed cow's milk after three and a half years of oral immunotherapy (OIT) with extensively hydrolyzed milk. The treatment consisted of gradually increasing the intake of hydrolyzed and partially hydrolyzed milk and reintroducing cow's milk. Despite some allergic reactions during treatment, the patient was able to consume more than 200 ml of milk consistently for more than six months without recurrence of symptoms. This case suggests the possibility of an alternative treatment for persistent CMA: not only OIT with cow's milk alone but also a safer introduction to treatment with extensively hydrolyzed formulas.

[Risk factors for cow's milk protein allergy in infants: a multicenter prospective nested case-control study]

OBJECTIVES

To explore the risk factors associated with cow's milk protein allergy (CMPA) in infants.

METHODS

This study was a multicenter prospective nested case-control study conducted in seven medical centers in Beijing, China. Infants aged 0-12 months were included, with 200 cases of CMPA infants and 799 control infants without CMPA. Univariate and multivariate logistic regression analyses were used to investigate the risk factors for the occurrence of CMPA.

RESULTS

Univariate logistic regression analysis showed that preterm birth, low birth weight, birth from the first pregnancy, firstborn, spring birth, summer birth, mixed/artificial feeding, and parental history of allergic diseases were associated with an increased risk of CMPA in infants (P<0.05). Multivariate logistic regression analysis revealed that firstborn (OR=1.89, 95%CI: 1.14-3.13), spring birth (OR=3.42, 95%CI: 1.70-6.58), summer birth (OR=2.29, 95%CI: 1.22-4.27), mixed/artificial feeding (OR=1.57, 95%CI: 1.10-2.26), parental history of allergies (OR=2.13, 95%CI: 1.51-3.02), and both parents having allergies (OR=3.15, 95%CI: 1.78-5.56) were risk factors for CMPA in infants (P<0.05).

CONCLUSIONS

Firstborn, spring birth, summer birth, mixed/artificial feeding, and a family history of allergies are associated with an increased risk of CMPA in infants.

Research progress on the mechanism of probiotics regulating cow milk allergy in early childhood and its application in hypoallergenic infant formula

Some infants and young children suffer from cow's milk allergy (CMA), and have always mainly used hypoallergenic infant formula as a substitute for breast milk, but some of these formulas can still cause allergic reactions. In recent years, it has been found that probiotic nutritional interventions can regulate CMA in children. Scientific and reasonable application of probiotics to hypoallergenic infant formula is the key research direction in the future. This paper discusses the mechanism and clinical symptoms of CMA in children. This review critically ex- amines the issue of how probiotics use intestinal flora as the main vector to combine with the immune system to exert physiological functions to intervene CMA in children, with a particular focus on four mechanisms: promoting the early establishment of intestinal microecological balance, regulating the body's immunity and alleviating allergic response, enhancing the intestinal mucosal barrier function, and destroying allergen epitopes. Additionally, it overviews the development process of hypoallergenic infant formula and the research progress of probiotics in hypoallergenic infant formula. The article also offers suggestions and outlines potential future research directions and ideas in this field.

Molecular Mechanism and Clinical Effects of Probiotics in the Management of Cow's Milk Protein Allergy

Cow's milk protein allergy (CMPA) is the most common food allergy (FA) in infancy, affecting approximately 2% of children under 4 years of age. According to recent studies, the increasing prevalence of FAs can be associated with changes in composition and function of gut microbiota or "dysbiosis". Gut microbiota regulation, mediated by probiotics, may modulate the systemic inflammatory and immune responses, influencing the development of allergies, with possible clinical benefits. This narrative review collects the actual evidence of probiotics' efficacy in the management of pediatric CMPA, with a specific focus on the molecular mechanisms of action. Most studies included in this review have shown a beneficial effect of probiotics in CMPA patients, especially in terms of achieving tolerance and improving symptoms.