World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines

Impact of processing on the sensitising capacity and cross-reactivity of cow's and camel milk proteins in a Brown Norway rat study

Infant formulas based on hydrolysed cow's milk proteins are used when breastfeeding is not feasible in cow's milk allergic infants. Camel milk has been shown to be well-tolerated by the majority of children with cow's milk allergy (CMA) and may be a substitute in management of CMA. Here we aimed to evaluate the impact of processing on immunogenicity, sensitising, antibody-binding and cross-reactive capacity of cow's and camel milk. Cow's and camel milk were processed by means of enzyme hydrolysis or heat treatment. Brown Norway rats were immunised with PBS, non-processed, enzyme hydrolysed or heat-treated cow's or camel milk. In vivo tests were performed for evaluation of clinical signs. Blood and faecal samples were analysed for levels and specificity of antibody responses. Cow's and camel milk showed similar sensitising capacity. Processing decreased the sensitising capacity of cow's milk, yet only enzyme hydrolysis but not heat treatment decreased the sensitising capacity of camel milk. Processing affected the specificity of antibodies raised in the rats, though the effect differed between cow's and camel milk. The study showed a low cross-reactivity between cow's and camel milk, which was decreased with processing, suggesting that processing of camel milk may improve its usefulness in CMA management.

Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper

The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.

Managing cow's milk protein allergy during the 2022 formula shortage: decision-making among pediatric healthcare providers

Introduction

Cow's milk protein allergy (CMPA) affects 2%-7% of infants and is managed with hypoallergenic formulas. The 2022 recalls of infant formulas due to factors including contamination led to specialty formula shortages, highlighting CMPA management challenges. Understanding healthcare providers' (HCPs) decision-making in transitioning to alternative formulas during shortages is crucial. Limited attention has been given to how pediatric physicians make these choices.

Methods

This study utilized US HCPs' de-identified survey data to assess driving factors when switching extensively hydrolyzed formulas during shortages.

Results

104 eligible HCPs participated, including general pediatrics, pediatric allergy/immunology, and pediatric gastroenterology specialists. Safety, tolerability, and efficacy were identified as top factors for switching formulas. Formula 1 was considered well-tolerated, patient-accepted, and safe by all HCPs. Most expressed strong belief in Formula 1's safety and effectiveness.

Discussion

Findings inform CMPA management during shortages, offering guidance to HCPs for suitable formula selection and enhanced infant care.

Dietary Management of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated food allergy-driven disease characterized by eosinophilic inflammation of the esophagus leading to symptoms of esophageal dysfunction. Prior studies have supported the key role of food allergen exposure as the main driver behind the etiopathogenesis showing that removal of food antigens can result in disease remission in both children and adults. These landmark studies serve as the basis for the rising interest and evolution of dietary therapy in EoE. This article will focus on the rationale for dietary therapy in EoE and provide helpful tools for the implementation of dietary therapy in practice.

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update - XII - Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA

Background

Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit.

Objective

These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA.

Methods

WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders.

Results

After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.The issued recommendations are labeled as "conditional" following the GRADE approach due to the very low certainty about the health effects based on the available evidence.

Conclusions

If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers' values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.

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.

Local Sources of Protein in Low- and Middle-Income Countries: How to Improve the Protein Quality?

Protein inadequacy is a major contributor to nutritional deficiencies and adverse health outcomes of populations in low- and middle-income countries (LMICs). People in LMICs often consume a diet predominantly based on staple crops, such as cereals or starches, and derive most of their daily protein intakes from these sources. However, plant-based sources of protein often contain low levels of indispensable amino acids (IAAs). Inadequate intake of IAA in comparison with daily requirements is a limiting factor that results in protein deficiency, consequently in the long-term stunting and wasting. In addition, plant-based sources contain factors such as antinutrients that can diminish protein digestion and absorption. This review describes factors that affect protein quality, reviews dietary patterns of populations in LMICs and discusses traditional and novel small- and large-scale techniques that can improve the quality of plant protein sources for enhanced protein bioavailability and digestibility as an approach to tackle malnutrition in LMICs. The more accessible small-scale food-processing techniques that can be implemented at home in LMICs include soaking, cooking, and germination, whereas many large-scale techniques must be implemented on an industrial level such as autoclaving and extrusion. Limitations and considerations to implement those techniques locally in LMICs are discussed. For instance, at-home processing techniques can cause loss of nutrients and contamination, whereas limitations with larger scale techniques include high energy requirements, costs, and safety considerations. This review suggests that combining these small- and large-scale approaches could improve the quality of local sources of proteins, and thereby address adverse health outcomes, particularly in vulnerable population groups such as children, adolescents, elderly, and pregnant and lactating women.

Mexican consensus on cow's milk protein allergy

BACKGROUND

The aim of this study is to present the current views of a diverse group of experts on the diagnosis and treatment of Cow's Milk Protein Allergy (CMPA) in children under 2 years of age in Mexico.

MATERIAL AND METHODS

The study, led by a scientific committee of five experts in CMPA, was divided into six phases, including a modified Delphi process. A total of 20 panelists, all of whom were pediatric specialists, participated in administering a comprehensive 38-item questionnaire. The questionnaire was divided into two blocks: Diagnosis and Treatment (20 items each).

RESULTS

Consensus was reached on all the proposed items, with an agreement rate of over 70% for each of them. As a result, a diagnostic and treatment algorithm was developed that emphasized the reduction of unnecessary diagnostic studies and encouraged breastfeeding whenever possible. In cases where breast milk is not available, appropriate use of hypoallergenic formulas was recommended. In addition, recommendations on treatment duration and gradual reintroduction of cow's milk protein were provided.

CONCLUSIONS

The recommendations endorsed by 20 Mexican pediatricians through this study are applicable to everyday clinical practice, thereby enhancing the diagnosis and treatment of children under 2 years of age with CMPA. This, in turn, will foster improved health outcomes and optimize the utilization of healthcare resources.

Exploring the links between necrotizing enterocolitis and cow's milk protein allergy in preterm infants: a narrative review

A broad range of allergic disorders and intolerance are associated with cow's milk protein in the infant diet. Allergy and intolerance to cow's milk proteins are commonly recognized in the healthy term infant, and the prevalence cow's milk protein intolerance (CMPI) varies widely but 5 challenge confirmed studies free from selection bias ranged from 1.9%-4.9%. These disorders are classified by the presence of IgE, non-IgE or T-cell-mediated signaling. Additionally, the severity of these adverse food reactions can range from mild gastrointestinal symptoms to severe sepsis-like episodes, as in the case of food protein-induced enterocolitis syndrome (FPIES). Food protein-induced intolerance in the healthy young infant lies in stark contrast to enterocolitis that typically occurs in the preterm neonate. Necrotizing enterocolitis (NEC) is a distinct progressive disease process, usually characterized by a high mortality rate, with a risk of death from 30% to 50%. While its exact etiology is unclear, its main triggers include formula (cow's milk protein), hypoxia, perfusion-related issues, and unregulated inflammation in the premature intestine. The distinction between NEC and cow's milk protein intolerance is difficult to discern in some cases. In the late preterm population, infants with colitis can have both NEC and cow's milk intolerance on the differential. In infants with multiple episodes of mild NEC, cow's milk protein intolerance may be the underlying diagnosis. In this review, we compare the pathophysiological characteristics, diagnosis and treatment of disorders of cow's milk protein intolerance with the entity of preterm NEC. This review highlights similarities in both entities and may inspire future cross-disciplinary research.

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

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

Food Allergies and Parasites in Children

The dynamically growing incidence of food allergies forces the scientific community to develop new methods for their diagnosis, differentiation, and effective treatment. Parasitoses appear much less frequently in the scientific literature, as well as among the presumed causes of numerous conditions. The similarity of inflammatory mechanisms in allergies and parasitosis necessitates a revision of current diagnostic standards. A lack of specificity and the coincidence of symptoms at an early stage of disease can lead to misdiagnosis. In this paper, we attempted to perform a comparative analysis of the similarities and differences in symptoms for these two types of diseases. We described the molecular mechanisms and metabolic pathways of food allergy and parasitosis. We presented the available research methods and directions of ongoing studies aimed at implementing precise medical techniques for differential diagnosis. We discussed the allergenic properties of certain parasite proteins, using the example of myofibrillar tropomyosins from the nematode Anisakis simplex. The literature in the fields of allergology and parasitology leads to the conclusion that it is reasonable to run parallel allergological and parasitological diagnostics in patients with non-specific symptoms. This approach will facilitate accurate and early diagnosis and implementation of effective therapy.

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.

The role of online symptom questionnaires to support the diagnosis of cow's milk allergy in children for healthcare professionals - A Delphi consensus study

BACKGROUND

Cow's milk allergy (CMA) is one of the most common food allergies world-wide. The emergence of online CMA symptom questionnaires, aimed at parents and/or healthcare professionals (HCP), may raise awareness about the possible diagnosis of CMA, but also increases the risk for overdiagnosis leading to unnecessary dietary restriction impacting on growth and nutrition. This publication sets out to establish the availability of these CMA symptom questionnaires and critically assesses the development and validity.

METHODS

Thirteen HCP working in the field of CMA, from different countries, were recruited to participate. A combination of a Pubmed and CINAHL literature and online review using the Google search engine in English language was used. Symptoms in the questionnaires were assessed, using the European Academy for Allergy and Clinical Immunology guidelines for food allergy. Following the assessment of both the questionnaires and literature, the authors followed the modified Delphi approach to generate consensus statements.

RESULTS

Six hundred and fifty-one publications were identified, of which 29 were suitable for inclusion, with 26 being associated with the Cow's Milk-Related Symptoms Score. The online search yielded 10 available questionnaires: 7/10 were sponsored by formula milk companies and 7/10 were aimed at parents and three at HCP. Following the assessment of data, 19 statements were generated in two rounds of anonymous voting reaching 100% agreement.

CONCLUSIONS

Online CMA questionnaires, available to parents and HCP's, are varied in symptoms, and most were not validated. The overarching consensus generated from authors is that these questionnaires should not be used without the involvement of HCP.

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.

Introduction of Complementary Foods and the Risk of Sensitization and Allergy in Children up to Three Years of Age

BACKGROUND

Allergy is known to be influenced by both diet and the immune system. In addition, the time of first exposure to food allergens and their type appear to play a particularly important role in the development of allergies.

AIM

To determine the influence of the time of exposure, and the type, degree of processing, and frequency of supply of complementary foods and the development of sensitization and allergies in children up to three years of age. Materials and metods: The study was conducted prospectively in two stages. The first stage included 106 children aged 6-18 months, while the second stage included 86 children selected from the first stage, after a further 12 months. A questionnaire based on validated FFQ sheets was created for the purpose of the study. The following were assessed: nutrition in the first year of life (time, type, degree of processing), frequency of supply of complementary foods and allergic symptoms, sIgE concentration against 10 foods and 10 inhalant allergens. Four groups of patients were formed. This paper presents the results of the second stage of the study.

RESULTS

For all participants, allergenic products, viz. hen's egg, milk, peanuts, wheat, soybean, fish, tree nuts and shellfish were typically introduced at an age of 7 to 12 months. During this period, egg white was introduced in 47 (85.5%) children with allergy (p = 0.894), in 29 (82.9%) with allergy and sensitization (p = 1.00), and in 38 (82.6%) children with sensitization alone (p = 0.533). Milk was introduced at 7 to 12 months in 35 (64.8%) children with allergy (p = 0.64), 22 (64.7%) with both allergy and sensitization (p = 0.815), and 26 (57.8%) children with sensitization alone (p = 0.627). For other foods, the time of introduction appeared not to significantly influence the presence of allergies or sensitization. Heat-treated peanuts were introduced significantly more often to children without allergies and without sensitization (n = 9; 56.2%) than those without allergies but with sensitization (n = 6; 54.5%) (p = 0.028). Fish was consumed significantly more often by children with allergies, i.e., 1-3x/week (n = 43; 79.6%) than children without allergies, i.e., 1-3x/month (n = 9; 30%) (p = 0.009).

CONCLUSIONS

No relationship was observed between the introduction time of complementary foods, including allergenic ones, or their type, and the development of allergies and sensitization in children up to three years of age. The degree of processing and the frequency of supply of products may affect the development of allergies and sensitization.

Plant-Based Milk Alternatives in Child Nutrition

Plant-based milk alternatives can be distinguished in two main categories, differing in production processes and regulation: plant-based formulas and plant-based drinks. They are now a widely accepted class of products on the international market. The various plant-based milk alternatives differ in nutritional characteristics due to their origin and manufacturing; more importantly, whereas formulas from plant and cow origin can be used interchangeably, plant-based drinks are nutritionally different from cow's milk and can be consumed by children subsequently to the use of formula. Several scientific organizations have expressed differing opinions on the use of these products in the diets of children. In the face of unanimous conclusions regarding the use of these products during the first year of life, in subsequent ages there were conflicting opinions regarding the timing, quantities, and type of product to be used. From the viewpoint of the child's overall diet and health, it could be suggested that these foods be considered not as simple substitutes for cow's milk, but as part of a varied diet, within individual advice of use. We suggest accepting the presence of these products in a baby's diet (omnivores included), planning their use correctly in the context of a balanced diet, according to the specific product and the needs of the individual.

Myths and misconceptions about childhood constipation

Many widely held beliefs and assumptions concerning childhood constipation continue to interfere with rational management of childhood constipation. Although many still believe that constipation is not a common disease, about 9.5% of the world's children suffer from chronic constipation. Most of these children live in non-Western countries. There are major misconceptions about the etiology of constipation as a significant proportion of clinicians still believe that constipation is caused by some form an organic pathology, whereas in reality, the majority have functional constipation. Contrary to a commonly held belief that children outgrow constipation without long-term problems, there is evidence that constipation leads to significant bowel and psychological consequences and has a major impact on the quality of life which detrimentally affects future health and education. Finally, ineffective management strategies such as increasing fiber and water in the diet, and short duration of treatment owing to the fear that long-term laxative treatment leads to colonic dysfunction, interfere with effective therapeutic strategies.   Conclusions: It is apparent that myths and misconception often lead to wrong assumptions regarding the distribution of the disease, its etiology, pathophysiology, and management leading to ordering incorrect investigations and ineffective therapeutic strategies while spending large sums of public funds unnecessarily. Poorly treated constipation leads to deleterious psychological consequences predisposing children to develop significant psychological damage and bowel dysfunctions. This review aims to challenge these myths about various elements of constipation by exploring the existing literature and encouraging clinicians to have a fresh look at old concepts that could interfere with the well-being of children with constipation. What is Known: • Childhood constipation is a growing problem in the world leading to significant suffering and high healthcare expenditure • Myths and misconceptions lead to poor management strategies causing psychological and bowel damage What is New: • Organic, systemic, and bowel disorders leading to constipation are uncommon, and in the majority, it arises due to deliberate fecal withholding and most investigations ordered by clinicians are not very helpful in the management • Most non-pharmacological interventions are not effective in the day-to-day management of childhood constipation. The use of laxatives is considered to be the first-line management strategy.

Nutritional Management of Children with Food Allergies

Purpose of the Review

The purpose of the review is to review the evidence for the nutritional management of paediatric food allergy and provide a practical approach for healthcare professionals working in this area.

Recent Findings

Dietary elimination remains the mainstay for management of food allergies in children. However, the elimination of food allergens increases the risk for growth faltering, micronutrient deficiencies and feeding difficulties. Breastmilk remains the ideal source of nutrition for infants, but when not available, the vast majority will tolerate an extensively hydrolysed formula, and rice hydrolysate has also been suggested as a suitable alternative. Only in severe cases, including anaphylaxis, eosinophilic oesophagitis and growth faltering, is an amino acid formula indicated. The early introduction of peanut and egg and avoiding the delay in the introduction of other allergens, when not already allergic, has been highlighted by recent studies.

Summary

Whilst the elimination of allergens increases the risk of developing poor growth, micronutrient deficiencies and feeding difficulties, optimal, early dietary input, including advice on active introduction of allergens and alternative feeds, ideally from a registered dietitian/nutritionist, may be prevent and improve outcomes.

Assessment of Selected Intestinal Permeability Markers in Children with Food Allergy Depending on the Type and Severity of Clinical Symptoms

Background: Food allergy (FA) has a broad range of symptoms, and clinical manifestations may concern several reactions from one system or organ. Aim: The aim of the study was to assess intestinal permeability (IP) based on the analysis of serum zonulin and bacterial lipopolysaccharides (LPS) levels in children with FA, taking into account the pathomechanism of immune reaction, clinical symptoms of FA and their severity. Material and methods: The study comprised 103 patients aged 7–60 months (median 34); 49 children with IgE-mediated allergy and 25 children with non-IgE-mediated allergy; the reference group comprised 29 children with functional gastrointestinal disorders. IP markers were determined using ELISA. Results: There was no correlation between the severity of clinical symptoms and the level of IP markers in children with FA. Zonulin and LPS levels were significantly higher in children with FA and gastrointestinal symptoms. Zonulin levels in the subgroup of children with non-IgE-mediated FA and gastrointestinal symptoms were significantly higher than in the subgroup of children with IgE-mediated FA and these symptoms. The level of LPS was significantly higher in the subgroup with IgE-mediated FA and atopic dermatitis. Conclusions: Zonulin and LPS levels were significantly higher in children with FA compared to children from the reference group. Zonulin levels were significantly higher in children with non-IgE-mediated FA than in children with IgE-mediated FA.

Four clinical phenotypes of cow’s milk protein allergy based on dairy product specific IgE antibody types in North China

Background

Cow’s milk protein allergy (CMPA) is a common allergy. Immunoglobulin E (IgE)-mediated cow’s milk allergy is associated with a high mortality risk and poor prognosis. The study aims to investigate whether there are different clinically CMPA phenotypes in China and to explore the association between CMPA phenotypes and specific IgE (sIgE) antibodies against different dairy products.

Methods

Serum sIgE against different animal milk and cow’s milk products and different milk components was measured by an allergen array. Four CMPA classifications were identified by the presence of serum sIgE: boiled milk-positive, yogurt-positive, buttermilk-positive, and raw milk-positive.

Results

Among the 234 participants included in the study, 9 were boiled milk sIgE-positive, 50 were yogurt sIgE-positive, 17 were buttermilk sIgE-positive, and 158 were only raw milk sIgE-positive. The boiled milk-positive group had the highest levels of raw milk sIgE and casein sIgE antibodies, followed sequentially by the yogurt-positive, buttermilk-positive, and raw milk-positive groups. The boiled milk group observed the highest levels of sIgE against raw milk, casein, α-lactalbumin, and β-lactoglobulin. These levels differed significantly from those in the other three groups. Allergic symptoms were distributed differently among the four study groups. The percentages of allergic patients with gastrointestinal tract symptoms in the above mentioned four groups ranged from high to low, and the percentages of patients with skin symptoms in the four groups ranged from low to high, respectively.

Conclusion

Based on dairy product sIgE antibody levels associated with different milk components and various clinical allergic symptom tendencies, we could distinguish four CMPA phenotypes.

Cow's milk allergy

PURPOSE OF REVIEW

To highlight the most recent insights on cow's milk allergy (CMA), its treatment, and management.

RECENT FINDINGS

CMA is one of the most common food allergies among children. Burdened by the risk for fatal reaction, CMA may imply also a severe impairment of health-related quality of life at individual and family level as well as well as individual and societal costs. The updated Diagnosis and Rationale for Action against Cow's Milk Allergy series is going to provide a series of manuscripts that will offer a comprehensive state-of-the-art specifically on CMA, including international evidence-based recommendations. The current results from randomized clinical trials highlight that oral immunotherapy may be effective by itself in providing desensitization. Preliminary data suggest that biologicals such as omalizumab may be able to increase the threshold of reactivity to milk or several foods (if multiple food allergies) without requiring allergen exposure. Breastfeeding is the first choice for infants with CMA. Extensively hydrolyzed formula and amino-acid formula are valid alternatives and may be particularly helpful when eliminating multiple foods, with severe complex gastrointestinal food allergies, eosinophilic esophagitis, severe eczema, or symptoms while exclusively breastfeeding. Heed is needed to ensure the formula is nutritionally sufficient. Due to a high degree of cross-reactivity with cow's milk proteins and risk for allergic reactions, goats' milk or other mammals' milk should not be used.

SUMMARY

The adoption and implementation of evidence-based recommendations may guide a proper diagnostics and management and awaited advances in knowledge will allow the development of a personalized treatment tailored on the specific CMA patient's profile.

Evaluation of the complementary feeding practices, dietary intake, and nutritional status of infants on a cow's milk protein elimination diet

OBJECTIVE

To evaluate the complementary feeding practices, food intake, and nutritional status of infants on a cow's milk protein elimination diet.

METHODS

A cross-sectional and observational study was conducted to compare infants aged 4-18 months who were on a cow's milk protein elimination diet with a control group of healthy infants without any dietary restrictions. General information on the child's health, demographic data, and food consumption were collected.

RESULTS

The study included 96 infants in the elimination diet group and 99 in the control group. In the elimination diet group, the median age (in months) of introduction of solid foods (5.0 × 4.0; p < 0.001) and water (5.5 × 4.0; p < 0.05) was later, consumption of soft drinks and industrialized cookies was less frequent (p < 0.05), and a lower index of complementary feeding inadequacies (2.75 × 3.50; p < 0.001) was observed. The elimination diet group presented lower individual values of Z scores for weight/age, weight/height, and body mass index/age, although they were fed with higher amounts of energy (117.4 × 81.3 kcal/kg of weight; p < 0.001) and macro-and micronutrients, except for vitamin A. In the elimination diet group, breast milk and its substitutes contributed to more than 67% of energy intake. Although calcium consumption was a deficit in 31.5% of the infants, none received supplementation.

CONCLUSION

Infants on an elimination diet presented more adequate complementary feeding practices and higher nutritional intake, despite lower body weight values.

The extended farm effect: The milk protein β-lactoglobulin in stable dust protects against allergies

Background: The allergy- and asthma-protective farm effect is mediated by numerous factors. Especially dust from cattle stables and raw cow’s milk show beneficial properties, suggesting a bovine protein to be involved. As a major milk protein and member of the lipocalin family, β-lactoglobulin (BLG) binds small, hydrophobic ligands and thereby modulates the immune response. Empty BLG promotes allergy development, whereas BLG in association with ligands shows allergy-preventive as well as allergy-reducing effects in vivo and in vitro. Results: BLG has been identified as a major protein in stable dust (therein bound to zinc) as well as in the air around cattle stables. This association with zinc favors an allergy-protective immune profile. Conclusion: Its immune-modulating, allergy-protective characteristics together with its presence in raw cow’s milk as well as in stable dust and ambient air render BLG an essential contributor to the farm effect.

Consensus on the diagnosis and treatment of cow's milk protein allergy of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein.

Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35-52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows' milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows' milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0-17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows' milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.

Electrochemical Methods for the Analysis of Milk

The milk and dairy industries are some of the most profitable sectors in many countries. This business requires close control of product quality and continuous testing to ensure the safety of the consumers. The potential risk of contaminants or degradation products and undesirable chemicals necessitates the use of fast, reliable detection tools to make immediate production decisions. This review covers studies on the application of electrochemical methods to milk (i.e., voltammetric and amperometric) to quantify different analytes, as reported over the last 10 to 15 years. The review covers a wide range of analytes, including allergens, antioxidants, organic compounds, nitrogen- and aldehyde containing compounds, biochemicals, heavy metals, hydrogen peroxide, nitrite, and endocrine disruptors. The review also examines pretreatment procedures applied to milk samples and the use of novel sensor materials. Final perspectives are provided on the future of cost-effective and easy-to-use electrochemical sensors and their advantages over conventional methods.

Semi-Elemental and Elemental Formulas for Enteral Nutrition in Infants and Children with Medical Complexity-Thinking about Cow's Milk Allergy and Beyond

Children with medical complexities, such as multi-system disorders and/or neurological impairments, often experience feeding difficulties and need enteral nutrition. They frequently have impaired motility and digestive-absorbing functions related to their underlying condition. If a cow's milk allergy (CMA) occurs as a comorbidity, it is often misdiagnosed, due to the symptoms' overlap. Many of the commercialized mixtures intended for enteral nutrition are composed of partially hydrolyzed cow's milk proteins, which are not suitable for the treatment of CMA; thus, the exclusion of a concomitant CMA is mandatory in these patients for obtaining symptoms relief. In this review, we focus on the use of elemental and semi-elemental formulas in children with neurological diseases and in preterm infants as clinical "models" of medical complexity. In children with neurodisabilities, when gastrointestinal symptoms persist despite the use of specific enteral formula, or in cases of respiratory and/or dermatological symptoms, CMA should always be considered. If diagnosis is confirmed, only an extensively hydrolyzed or amino-acid based formula, or, as an alternative, extensively hydrolyzed nutritionally adequate formulas derived from rice or soy, should be used. Currently, enteral formulas tailored to the specific needs of preterm infants and children with neurological impairment presenting concomitant CMA have not been marketed yet. For the proper monitoring of the health status of patients with medical complexity, multidisciplinary evaluation and involvement of the nutritional team should be promoted.

The Basophil Activation Test for Clinical Management of Food Allergies: Recent Advances and Future Directions

The basophil activation test (BAT) is an ex vivo functional assay that measures by flow cytometry the degree of basophil degranulation after stimulation with an allergen. In recent years, there has been an increased interest in the diagnostic value of the BAT as it has the potential to mimic the clinical phenotype of sIgE sensitized patients, in contrast to allergen-specific IgE levels. This diagnostic potential would be of particular interest for food allergies present early in life such as peanut, cow’s milk and eggs, which require an expensive, time-consuming and patient unfriendly oral food challenge (OFC) for diagnosis. However, routine applications of the BAT for clinical use are not yet feasible due to the lack of standardized protocols and large clinical validation studies. This review will summarize the current data regarding the application of the BAT in food allergy (FA) for cow’s milk, egg and peanut, being the most common causes of FA in children. Additionally, it will discuss the hurdles for widespread clinical use of the BAT and possible future directions for this diagnostic procedure.

Prevalence, Risk Factors, Clinical Manifestation, Diagnosis Aspects and Nutrition Therapy in Relation to both IgE and IgG Cow’s Milk Protein Allergies among a Population of Saudi Arabia: A Literature Review

Cow milk protein allergy (CMPA) becoming a major public health issue that has attracted the attention of health professionals and researchers. This paper aimed to review the important aspects of both IgE and IgG types of cow’s milk protein allergy in terms of prevalence, clinical manifestation, risk factors, other health-related issues and nutritional therapy proposed for such allergies in the adult and pediatric population in Saudi Arabia. A search on “cow’s milk allergy” was done using PubMed, Google Scholar and Scopus Engine for published papers between 1993 and 2020 to find studies yielding knowledge on that context. The prevalence of cow’s milk protein allergy (CMPA) among infants is now in the range of 2–3%. This type of allergy is also detected in adulthood but less frequently. CMPA is defined as an immunological reaction to specific proteins in milk. CMPA is classified based on its type as an immunoglobulin E (IgE)-mediated form and an immunoglobulin G (IgG)-mediated form, each type representing different immunological pathways. The presence of Genetic aspects, family history and short duration of breastfeeding in the infant are among the risk factors contributing to this form of allergy. Its manifestations mainly present as skin presentation, followed by the gastrointestinal and respiratory presentation in most cases in addition to a life-threatening anaphylactic reaction that may occur in 12% of cases. food allergy committees have developed strict diagnosis criteria, including blood testing for food-specific immunoglobulin E (sIgE), a skin prick test and double-blind placebo-controlled food challenges (DBPCFC) as the gold standard. A diet free of cow’s milk protein (CMP) allergen and including the appropriate alternative milk formula is the first line of prevention recommended by many organizations and food allergy experts. As for Saudi Arabia, more research and clinical trials are required to discuss the various aspects of adult and pediatric CMPA and to provide a better understanding along with good control strategies implementation.

Hydrolysed Formulas in the Management of Cow's Milk Allergy: New Insights, Pitfalls and Tips

An allergy to cow's milk requires the avoidance of cow's milk proteins and, in some infants, the use of a hypoallergenic formula. This review aims to summarize the current evidence concerning different types of hydrolysed formulas (HF), and recommendations for the treatment of IgE- and non-IgE-mediated cow's milk allergy and functional gastrointestinal disorders in infancy, for which some dietary intervention and HF may be of benefit to both immune and motor mechanisms. Current guidelines recommend cow's milk protein (i.e., whey or casein) extensively hydrolysed formula (eHF) as the first choice for cow's milk allergy treatment, and amino acid formulas for more severe cases or those with reactions to eHF. Rice hydrolysed formulas (rHF) have also become available in recent years. Both eHF and rHF are well tolerated by the majority of children allergic to cow's milk, with no concerns regarding body growth or adverse effects. Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics. Despite encouraging results on tolerance acquisition, evidence is still not conclusive, thus hampering our ability to draw firm conclusions. In clinical practice, the choice of hypoallergenic formula should be based on the infant's age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy.

Immunonutrition for Pediatric Patients With Cow's Milk Allergy: How Early Interventions Could Impact Long-Term Outcomes

Cow's milk allergy (CMA) is one of the most common food allergies and one of the main causes of food-induced anaphylaxis in the pediatric age. Moreover, up to 45% of CMA children develop other atopic manifestations later in life, a phenomenon commonly named atopic march. Thus, CMA imposes a significant cost to health care systems as well as to families, and has emerged as one of the most expensive allergic diseases. The immunonutrition strategy builds its foundation on the ability of selected dietary factors to modulate immune system development and function. Recent studies highlighted the potential of immunonutrition in the management of CMA. This review is focused on the mechanisms and long-term clinical outcomes of the immunonutrition approach in children with CMA.

Tolerability of a new amino acid-based formula for children with IgE-mediated cow's milk allergy

BACKGROUND

Amino acid-based formula (AAF) is a relevant dietary strategy for paediatric patients affected by cow's milk allergy (CMA). The present study was designed to evaluate the hypoallergenicity of a new AAF in children with immunoglobulin (Ig)E-mediated CMA.

METHODS

According to the criteria provided by the American Academy of Pediatrics Subcommittee on Nutrition and Allergic Diseases, we designed a prospective trial in CMA children (aged 1-36 months) aimed to demonstrate the hypoallergenicity of the new AAF in 90% of subjects with 95% confidence during the double-blind, placebo-controlled challenge (DBPCFC). A skin prick test (SPT) with the new AAF was also performed.

RESULTS

Twenty-nine children [all Caucasian, 55.2% male, mean age (±SD) 16.9 ± 5.7 months] were enrolled. The SPT and the DBPCFC with the new AAF were negative in all study subjects.

CONCLUSIONS

The study results support the hypoallergenicity of the new AAF. This formula could be considered an additional dietary option for non-breastfed children affected by CMA.

TRIAL REGISTRATION

The trial was registered in the ClinicalTrials.gov Protocol Registration System (ID number: NCT03909113 ).

Nutritional Management With a Casein-Based Extensively Hydrolysed Formula in Infants With Clinical Manifestations of Non-IgE-Mediated CMPA Enteropathies and Constipation

Background: The majority of mixed-fed infants with non-IgE-mediated cow's milk protein allergy (CMPA) enteropathies are managed with an extensively hydrolysed cow's milk based infant formula (eHF). Given the high variability in peptide distribution of available eHFs, it is important to understand the suitability of a specific product in the management of distinct phenotypes.

Objective: To assess the symptom resolution of various phenotypes of clinical manifestations of CMPA enteropathies and constipation managed by a casein-based eHF.

Methods: The data of 20 full-term infants (n = 15 with non-IgE-mediated CMPA and n = 5 with constipation) attending a paediatric allergy clinic in Cyprus and managed with a casein-based eHF were retrospectively analysed.

Results: Based on the clinical symptoms and history, infants were classified into the following phenotypes: (a) 11/15 (73.3%) FPIAP, (b) 3/15 (20%) FPIES, and (c) 1/15 (6.7%) severe diarrhoea. Overall, 14 (93.3%) patients were successfully managed with the casein-based eHF and 1 (6.7%) required an AAF. This formula was effective in 91% of patients with FPIAP, in 100% with FPIES and with diarrhoea. Three (60%) patients with constipation responded to the eHF.

Conclusion: This case-series report supports the efficacy of a particular casein-based eHF for the nutritional management of non-IgE mediated CMPA enteropathies.

Potential beneficial effects of kefir and its postbiotic, kefiran, on child food allergy

Food allergies are known as the public health problem, affecting people of all age groups, but more commonly in babies and children, with consequences for nutritional status and quality of life. The increase in the consumption of healthy foods has consequently led to an increased demand for functional foods with specific health benefits. Thus, the pharmaceutical industry's interest in natural products has grown every time and is therefore considered as an alternative to synthetic drugs. Kefir has been outstanding for several years as promising in the manufacture of various pharmaceutical products, due to its nutritional and therapeutic properties for the treatment of many diseases. Currently, a wide variety of new functional foods are appearing on the market, representing an important segment. Postbiotics, for example, has stood out for being a product with action similar to probiotics, without offering side effects. The kefiran is the postbiotic from kefir that promotes potential beneficial effects on food allergy from the intestinal microbiome to the immune system. In this context, it is necessary to know the main promoting component of this functional effect. This review compiles the benefits that kefir, and especially its postbiotic, kefiran, can bring to food allergy. In addition, it serve as a subsidy for studies on the development of innovative nutraceutical products, including the use of kefiran as an alternative therapy in food allergy.

Early introduction oral immunotherapy for IgE-mediated cow's milk allergy: A follow-up study confirms this approach as safe and appealing to parents

INTRODUCTION

Early introduction oral immunotherapy (E-OIT) in the first year of life can be a safe treatment for infants with cow's milk allergy (CMA). Once the protocol is completed, doubts remain whether children achieve tolerance or remain desensitized. According to current guidelines, this is determined by an avoidance period followed by a re-exposure to the food allergen during an in-hospital oral food challenge (OFC). In real life, this approach can be complicated, time-consuming, and anxiety-provoking for parents. We assessed the long-term safety of E-OIT for CMA in a cohort of children who switched to an unrestricted diet without testing the achievement of tolerance at the end of the OIT protocol.

MATERIALS AND METHODS

We performed a descriptive analysis of the clinical follow-up of a cohort of children diagnosed with IgE-mediated CMA and undergoing E-OIT protocol in their first year of life. In a previous publication, the same cohort of patients had been studied to assess the feasibility of E-OIT for CMA. In the present study, we reported the results of a telephone survey, carried out through a questionnaire to their families enquiring about milk consumption and other ongoing atopic conditions of children.

RESULTS

After an average of 4 years from the start of E-OIT, 62/73 patients (85% of the historical cohort) participated in the survey. Among them, all 56 patients who had previously successfully completed the protocol reported an unrestricted cow's milk intake. Ninety-three percent of these children did not experience any further allergic reactions, while the remaining 7% described only mild and transitory reactions until the 6-month period after the end of the protocol.

CONCLUSIONS

This study confirmed the long-term safety of E-OIT for CMA and challenged the paradigm of the need for allergen food withdrawal to discern between desensitization and tolerance. It could be a starting point for planning future trials on this issue.

Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns

Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.

Assessment of Inflammatory Markers in Children with Cow's Milk Allergy Treated with a Milk-Free Diet

Background: The aim of the study was to establish whether the use of a strict milk-free diet in children with cow’s milk allergy, resulting in the resolution of clinical symptoms of the disease, also extinguishes the inflammatory reaction induced by the allergy. Methods: We examined 64 children (aged 3–6 years) with a diagnosed cow’s milk allergy who had been treated with an elimination diet for at least six months and showed remission of the disease’s clinical symptoms as a result of the treatment. The control group consisted of 30 healthy children of the same age following an unrestricted age-appropriate diet. Concentrations of cytokines, calprotectin, and adipokines (leptin, resistin, chemerin, neutrophilic lipocalin associated with gelatinase—NGAL) were determined in the serum samples obtained from the studied children by immunoenzymatic assays. Results: Patients with CMA had significantly higher median values of serum IL-6, TNF-α, resistin, chemerin and NGAL in comparison to the healthy children (p < 0.05, p < 0.001, p < 0.05, p < 0.01, p < 0.001, respectively). Serum concentrations of IL-10, leptin, calprotectin and CRP as well as in WBC count were in the same range in both studied groups. We observed direct statistically significant correlations between levels of IL-10 and CRP (p = 0.005), IL-10 and WBC (p = 0.045), TNF-α and WBC (p = 0.038), calprotectin and WBC (p < 0.001), chemerin and CRP (p < 0.001) as well as between NGAL and WBC (p = 0.002) in children with CMA. Conclusion: The use of a strict milk-free diet by children with CMA, resulting in the resolution of clinical symptoms of the disease, does not seem to extinguish the inflammation induced by the allergy. The findings of this study—elevated IL-6, TNF-α, resistin, chemerin and NGAL levels in patients with CMA—suggest that these parameters seem to be involved in the generation of a low-grade proinflammatory environment observed in cow‘s milk allergy and could be used to monitor the effectiveness of treatment.

Early Nutrition and Risk of Type 1 Diabetes: The Role of Gut Microbiota

Type 1 diabetes (T1D) appears most frequently in childhood, with an alarming increasing incidence in the last decades. Although the genetic predisposition is a major risk factor, it cannot solely explain the complex etiology of T1D which is still not fully understood. In this paper, we reviewed the most recent findings on the role of early nutrition and the involvement of the gut microbiota in the etiopathogenesis of T1D. The main conclusions that are withdrawn from the current literature regarding alleviating the risk of developing T1D through nutrition are the encouragement of long-term breast-feeding for at least the first 6 months of life and the avoidance of early complementary foods and gluten introduction (before 4 months of age) as well as cow milk introduction before 12 months of life. These detrimental feeding habits create a gut microbiota dysbiotic state that can contribute to the onset of T1D in infancy. Finally, we discussed the possibility to introduce probiotics, prebiotics and post-biotics in the prevention of T1D.

Do adults and older people follow current guidelines for milk consumption?

OBJECTIVE

To estimate the prevalence of frequent milk consumption (≥five times/week), the consumption of low-fat/skimmed milk and associated factors in adults and older people, evaluating adherence to current Brazilian guideline.

DESIGN

Population-based cross-sectional study involving the analysis of data from the 2015 Campinas Food Intake and Nutritional Status and 2015 Campinas Health Survey. The prevalence of milk consumption was analysed according to socio-economic characteristics, morbidities and health-related behaviours.

SETTING

City of Campinas, state of São Paulo, Brazil.

PARTICIPANTS

A sample of 1710 participants of the 2015 Campinas Nutritional and Health Surveys.

RESULTS

A total of 73·8 % of the population consumed milk, but the prevalence of frequent consumption was only 44·0 %. Frequent milk consumption was higher among women, older people and individuals with better diet quality. A total of 18·4 % of the individuals who consumed milk reported consuming low-fat/skimmed milk; this prevalence was higher among women, individuals with a higher socio-economic status, those with better diet quality and those with chronic diseases.

CONCLUSION

Despite the high nutritional quality of milk and the different types available on the market, adults and older people do not follow current recommendations regarding its consumption. Information on the nutritional quality of milk and current recommendations should be disseminated more at healthcare services.

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.

Digestomics of Cow's Milk: Short Digestion-Resistant Peptides of Casein Form Functional Complexes by Aggregation

The aim of this study was to identify short digestion-resistant peptides (SDRPs) released by pepsin digestion of the whole cow’s milk and examine their IgE reactivity and allergenicity. Raw milk was subjected to simulated gastric digestion. SDRPs were fractionated from the digests and identified by MS. Milk SDRPs were evaluated for aggregability, propensity to compete for IgE binding with individual milk allergens, and ability to bind IgG4 from allergic and milk-tolerant individuals. The majority of milk SDRPs originated from caseins (97% of peptides) and overlapped with the known IgE epitopes of cow’s milk allergens. SDRPs competed with milk proteins for binding to human IgE and readily formed aggregates. The average peptide length was 10.6 ± 3.5 amino acids. The ability to provoke allergenic in vivo responses was confirmed by skin-prick testing (SPT) in five milk-allergic subjects. This was attributed to the peptide ability to aggregate into non-covalent complexes. SDRPs are able to induce response in SPT, but only in 50% of the sera SDRPs were able to inhibit IgG4 binding to caseins. Hence, SDRPs corresponding to the mainly continuous epitopes of milk proteins induce allergenic in vivo responses in milk-allergic subjects due to aggregation.

A Latin American and Spanish pediatric gastroenterology group's understanding of cow's milk protein allergy diagnosis and treatment: Results of a survey by the Food Allergy Working Group of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica

INTRODUCTION

There are discrepancies in the diagnosis and management of cow's milk protein allergy (CMPA) in Spain and Latin America. The aim of the present study was to find out how Spanish and Latin American pediatric gastroenterologists diagnose and treat CMPA.

MATERIAL AND METHODS

Pediatric gastroenterologists, members of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición, were invited to fill out a structured survey, the results of which were then compared with the 2012 and 2014 diagnosis and treatment guidelines, respectively.

RESULTS

The survey results showed that 17% of the participants follow the diagnostic recommendations based on the published consensus and guidelines. To diagnose non-IgE-mediated CMPA, 15% of the participants utilize IgE-specific skin prick tests, 22% use IgE-specific blood tests, and 45% employ oral food challenges. To diagnose IgE-mediated CMPA the percentages for the same diagnostic methods were 57, 83 and 22%, respectively. Once diagnosis is confirmed, 98% of the participants provide dietary recommendations. In children that are not breastfed, 89% of the participants prescribe an initial extensively hydrolyzed formula, 9% an amino acid formula, 1% a soy formula, and 1% a hydrolyzed rice formula. In patients with IgE-mediated CMPA, 34% of the participants carry out an oral challenge once treatment is completed, 39% according to symptom severity, and 27% in relation to IgE-specific testing.

CONCLUSION

CMPA management is diverse and there is poor adherence to the clinical practice guidelines.