Synbiotics-supplemented amino acid-based formula supports adequate growth in cow's milk allergic infants

Comparison of 11 Formulas and Breastfeeding for Atopic Dermatitis and Growth in Pediatric Cow's Milk Protein Allergy: A Systematic Review and Network Meta-Analysis of 23 Randomized Controlled Trials

OBJECTIVE

This study aimed to evaluate the effectiveness of various formulas and the ability of breastfeeding with the exclusion of cow milk protein to reduce the Scoring Atopic Dermatitis (SCORAD) index and promote growth in infants with cow milk protein allergy.

METHODS

We conducted a systematic search of PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, China National Knowledge Infrastructure, WanFang Data, Weipu, and the China Biomedical Literature Database. The search period ranged from the inception of each database to December 2023 (with an update until January 15, 2025). We included randomized controlled trials (RCTs) comparing formulas and breastfeeding for cow's milk protein allergy in infants. Two independent reviewers extracted data via standardized methods and assessed the risk of bias via the revised Cochrane risk-of-bias 2.0 tool. We performed a network meta-analysis (NMA) via a Bayesian fixed-effects model in RStudio and assessed the certainty of the evidence via the Confidence in Network Meta-Analysis (CINeMA) online application. The protocol for this NMA was preregistered in PROSPERO (No. CRD42024504707).

RESULTS

This analysis included 23 RCTs involving 1997 children and assessed 12 interventions. Compared with the regular formula, the pectin-thickened amino acid formula (TAAF) might reduce the SCORAD index (-12.49, 95% confidence interval [CI] -20.38 to -4.48, low certainty). At ≤6 months of follow-up, compared with rice-hydrolyzed formula (RHF), breastfeeding might improve the length-for-age Z score (LAZ) (0.47, 95% CI 0.13-0.81, moderate certainty), and breastfeeding (0.39, 95% CI 0.02-0.77, low certainty) and extensively hydrolyzed formula (EHF) with probiotics (0.38, 95% CI 0.00-0.77, low certainty) might respectively improve the weight-for-age Z score (WAZ) and weight-for-length Z score (WLZ). At the 12-month follow-up, EHF might improve the LAZ (0.41, 95% CI 0.11-0.71, low certainty) and WLZ (0.37, 95% CI 0.18-0.56, low certainty) compared with RHF, whereas the amino acid formula (AAF) may improve the WAZ (0.33, 95% CI 0.02-0.63, low certainty).

CONCLUSIONS

Low-certainty evidence suggested that TAAF might reduce the SCORAD index. Moderate or low certainty evidence indicated that, at ≤6 months of follow-up, breastfeeding might improve the LAZ and WAZ, whereas EHF with probiotics might improve the WLZ. At the 12-month follow-up, EHF might improve the LAZ and WLZ, whereas AAF might improve the WAZ. However, further high-quality studies would be needed to confirm these findings and assess their safety and cost-effectiveness.

Gut microbiota in infants with food protein enterocolitis

BACKGROUND

We explored the effects of two formulas, extensively hydrolyzed formula (EHF) and amino acid-based formula (AAF), on the gut microbiota and short-chain fatty acids (SCFAs) in infants with food protein-induced enterocolitis syndrome (FPIES).

METHODS

Fecal samples of thirty infants with bloody diarrhea receiving EHF or AAF feeding were collected at enrollment, diagnosis of FPIES, and four weeks after diagnosis. The gut microbiota and SCFAs were analyzed using 16 S rRNA gene sequencing and gas chromatography-mass spectrometry, respectively.

RESULTS

Microbial diversity of FPIES infants was significantly different from that of the controls. FPIES infants had a significantly lower abundance of Bifidobacterium and a higher level of hexanoic acid compared with controls. In EHF-fed FPIES infants, microbial richness was significantly decreased over time; while the microbial diversity and richness in AAF-fed FPIES infants exhibited no differences at the three time points. By four weeks after diagnosis, EHF-fed FPIES infants contained a decreased abundance of Acinetobacter, whereas AAF-fed FPIES infants contained an increased abundance of Escherichia-Shigella. EHF-fed infants experienced significantly decreased levels of butyric acid and hexanoic acid at four weeks after diagnosis.

CONCLUSIONS

Infants with FPIES had intestinal dysbiosis and different formulas differentially affected gut microbiota and SCFAs in FPIES infants.

IMPACT

We firstly report the impacts of two different nutritional milk formulas on the gut microbial composition and SCFAs levels in infants with FPIES. We show that infants with FPIES have obvious intestinal dysbiosis and different formulas differentially affect gut microbiota and SCFAs in FPIES infants. Understanding the effects of different types of formulas on gut microbial colonization and composition, as well as the related metabolites in infants with FPIES could help provide valuable insights for making choices about feeding practices.

EFSA Panel on Food Additives and Flavourings (FAF), Castle L, Andreassen M, Aquilina G, Bastos ML, Boon P, Fallico B, FitzGerald R, Frutos Fernandez MJ, Grasl‐Kraupp B, Gundert‐Remy U, Gürtler R, Houdeau E, Kurek M, Louro H, Passamonti S, Wölfle D, Dusemund B, Turck D, Barmaz S, Tard A, Rincon AM. Re-evaluation of citric acid esters of mono- and diglycerides of fatty acids (E 472c) as a food additive in foods for infants below 16 weeks of age and follow-up of its re-evaluation

Citric acid esters of mono- and diglycerides of fatty acids (E 472c) was re-evaluated in 2020 by the Food Additives and Flavourings Panel (FAF Panel) along with acetic acid, lactic acid, tartaric acid, mono- and diacetyltartaric acid, mixed acetic and tartaric acid esters of mono- and diglycerides of fatty acids (E 472a,b,d,e,f). As a follow-up to this assessment, the FAF Panel was requested to assess the safety of citric acid esters of mono- and diglycerides of fatty acids (E 472c) for its use as food additive in food for infants below 16 weeks of age belonging to food categories (FCs) 13.1.1 (Infant formulae as defined by Directive 2006/141/EC) and 13.1.5.1 (Dietary foods for infants for special medical purposes and special formulae for infants). In addition, the FAF Panel was requested to address the recommendation of the re-evaluation of E 472c as a food additive to update the EU specifications in Commission Regulation (EU) No 231/2012. For this, a call for data was published to allow interested partied to provide the requested information for a risk assessment. The Panel concluded that the technical data provided by the interested business operators support an amendment of the EU specifications for E 472c. Regarding the safety of the use of E 472c in food for infants below 16 weeks of age, the Panel concluded that there is no safety concern from its use at the reported use levels and at the maximum permitted levels in food for infants below 16 weeks of age (FCs 13.1.1 and 13.1.5.1).

Exploring the Fecal Metabolome in Infants With Cow's Milk Allergy: The Distinct Impacts of Cow's Milk Protein Tolerance Acquisition and of Synbiotic Supplementation

SCOPE

Cow's milk allergy (CMA) is one of the most prevalent food allergies in early childhood, often treated via elimination diets including standard amino acid-based formula or amino acid-based formula supplemented with synbiotics (AAF or AAF-S). This work aimed to assess the effect of cow's milk (CM) tolerance acquisition and synbiotic (inulin, oligofructose, Bifidobacterium breve M-16 V) supplementation on the fecal metabolome in infants with IgE-mediated CMA.

METHODS AND RESULTS

The CMA-allergic infants received AAF or AAF-S for a year during which fecal samples were collected. The samples were subjected to metabolomics analyses covering gut microbial metabolites including SCFAs, tryptophan metabolites, and bile acids (BAs). Longitudinal data analysis suggested amino acids, BAs, and branched SCFAs alterations in infants who outgrew CMA during the intervention. Synbiotic supplementation significantly modified the fecal metabolome after 6 months of intervention, including altered purine, BA, and unsaturated fatty acid levels, and increased metabolites of infant-type Bifidobacterium species: indolelactic acid and 4-hydroxyphenyllactic acid.

CONCLUSION

This study offers no clear conclusion on the impact of CM-tolerance acquisition on the fecal metabolome. However, our results show that 6 months of synbiotic supplementation successfully altered fecal metabolome and suggest induced bifidobacteria activity, which subsequently declined after 12 months of intervention.

Growth in healthy infants with cow's milk protein allergy fed extensively hydrolyzed or amino acid-based formulas

BACKGROUND

Cow's milk protein allergy (CMPA) is one of the most common food allergies in the first year of life. Special formulas for infants with CMPA include extensively hydrolyzed (EHFs) and amino acid-based (AAFs) formulas. The aim of this study was to evaluate the growth of infants fed with these special formulas.

METHODS

This was a prospective chart review study that evaluated the growth criteria of infants with CMPA fed with EHFs or AAFs until one year of age. These infants were referred to the gastroenterology clinic of Bahrami Children's Hospital from April 2021 to April 2022. These infants were divided into two groups, the group fed with EHFs and AAFs. Then growth criteria were evaluated in both groups.

RESULTS

Fifty-eight children were enrolled in the study, of which 51.7% were girls. Forty were consuming the EHFs formulas. The median time of both diagnosis and treatment was 60 days. The most common clinical manifestations were gastroesophageal reflux, dysentery, eczema, vomiting, and cough, respectively. The diagnosis of the disease in the AAFs group was significantly earlier than in the other group. The growth of children in both groups was completely proportional to their age and growth criteria at birth. Comparing the groups, all growth parameters were higher in the EHFs group.

CONCLUSION

This study showed that the growth criteria (weight, length, and head circumference) were suitable for each group and were in accordance with the WHO growth charts compared to the birth criteria. But in the group fed with EHFs, compared to AAFs, the growth rate was higher.

A synbiotic of Anaerostipes caccae and lactulose prevents and treats food allergy in mice

Depletion of beneficial microbes by modern lifestyle factors correlates with the rising prevalence of food allergies. Re-introduction of allergy-protective bacteria may be an effective treatment strategy. We characterized the fecal microbiota of healthy and food-allergic infants and found that the anaerobe Anaerostipes caccae (A. caccae) was representative of the protective capacity of the healthy microbiota. We isolated a strain of A. caccae from the feces of a healthy infant and identified lactulose as a prebiotic to optimize butyrate production by A. caccae in vitro. Administration of a synbiotic composed of our isolated A. caccae strain and lactulose increased luminal butyrate in gnotobiotic mice colonized with feces from an allergic infant and in antibiotic-treated specific pathogen-free (SPF) mice, and prevented or treated an anaphylactic response to allergen challenge. The synbiotic's efficacy in two models and microbial contexts suggests that it may be a promising approach for the treatment of food allergy.

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

BACKGROUND

The Step-Down Approach for Cow's Milk Allergy (SDACMA) trial evaluated the tolerability and the rate of immune tolerance acquisition in CMA children starting dietary treatment with amino acid-based formula (AAF) and then switching to EHCF containing the probiotic Lacticaseibacillus  rhamnosus GG (EHCF + LGG).

METHODS

Randomized controlled trial involving IgE-mediated CMA children receiving AAF from at least 4 weeks. EHCF + LGG tolerance was evaluated by the results of double-blind placebo-controlled food challenge (DBPCFC). Subjects tolerating EHCF + LGG were randomly allocated to remain on AAF, or to switch to EHCF + LGG. Immune tolerance acquisition to cow's milk proteins was evaluated with DBPCFC after 12 months of treatment. Allergy screening tests and body growth were also monitored.

RESULTS

Sixty IgE-mediated CMA children were enrolled. The proportion of children treated with AAF who resulted tolerant to the first exposure of EHCF + LGG was 0.98 (exact 95% CI 0.91-0.99). The rate of the immune tolerance acquisition to cow milk proteins after 12 months treatment was higher in the EHCF + LGG (0.48, 95% exact CI 0.29-0.67, n/N = 14/29) than in the AAF group (0.03, 95% exact CI 0.001-0.17, n/N = 1/30). There was an absolute benefit increase (ABI) of tolerance rate equal to 0.45 (95% CI 0.23-0.63, Newcombe method 10) for EHCF + LGG versus AAF, corresponding to a NNT of 2 (2-4, Bender's method). A normal body growth pattern was observed in the two study groups.

CONCLUSION

In IgE-mediated CMA children the step-down from AAF to EHCF + LGG is well tolerated and could facilitate the immune tolerance acquisition.

Nutraceuticals Prepared with Specific Strains of Probiotics for Supplementing Gut Microbiota in Hosts Allergic to Certain Foods or Their Additives

Certain nutrients cause discomfort, sensitivity reaction, and an intolerance for certain foods or their ingredients when ingested by some consumers. Food reactions and gut inflammation-related problems are increasing worldwide. The primary form of management would be the avoidance of such foods, followed by treatment of their symptoms. Adopting a nutritional-therapeutic approach and establishing practices for the inclusion of functional foods and nutraceuticals in the diet could improve the ecology of gut microbiota and alleviate inflammation in the GIT. For this purpose, specific species of microorganisms characterized as probiotic strains have been studied to produce functional food and fermented beverage products. Commercially sold, such items are labelled as probiotic products, displaying the name/s of strain/s and the viable numbers of them contained in the portion size of the products. The importance of the growth of probiotic functional foods is that they can be consumed as a source of nutrition and their intake helps in the subsistence and recuperation of friendly gut bacteria. Probiotics have been reported for their role in ameliorating the risk of food reactions. Probiotic administration has been implemented for its role as an auxiliary improvement and for the prevention of food sensitivities common among pediatric patients. Probiotic products based on non-dairy substrates have potential as nutraceuticals for lactose intolerant consumers who are allergic to dairy milk products. Therefore, the aim of this article is to review GRAS microbial species characterized as probiotics up to the level of their specific strain's name and/or number. These have been used to produce nutraceuticals that are sources of beneficial bacteria for easing discomfort and allergic reactions by maintaining an inflammation-free gut.

Body growth assessment in children with IgE-mediated cow's milk protein allergy fed with a new amino acid-based formula

Background

Amino acid-based formula (AAF) is a relevant dietary option for non-breastfed children. The present study was designed to evaluate the body growth pattern in cow's milk protein allergy (CMPA) children treated for 6 months with a new AAF.

Methods

This was an open-label, single arm study evaluating body growth pattern in immunoglobulin E (IgE)-mediated CMPA infants receiving a new AAF for 6 months. The outcomes were anthropometry (weight, length, head circumference), adherence to the study formula and occurrence of adverse events (AEs).

Results

Fifteen children [all Caucasian and born at term; 53.3% born with spontaneous delivery; 80% male; 80% with familial allergy risk; mean age (±SD) 3 ± 2.5 months at IgE-mediated CMPA diagnosis; mean age (±SD) 16.7 ± 5.9 months at enrolment, mean total serum IgE (±SD) 298.2 ± 200.4 kU/L] were included and completed the 6-month study. Data from fifteen age- and sex-matched healthy controls were also adopted as comparison. At baseline, all CMPA patients were weaned and were receiving the new AAF. All 15 patients completed the 6-month study period. For the entire CMPA pediatric patients’ cohort, from baseline to the end of the study period, the body growth pattern resulted within the normal range of World Health Organization (WHO) growth references and resulted similar to healthy controls anthropometric values. The formula was well tolerated. The adherence was optimal and no AEs related to AAF use were reported.

Conclusions

The new AAF ensured normal growth in subjects affected by IgE-mediated CMPA. This formula constitutes another suitable safe option for the management of pediatric patients affected by CMPA.

Current Use of Probiotics and Prebiotics in Allergy

The microbiome plays an important role in the pathogenesis of allergic diseases. This review updates the reader on studies aimed at influencing allergic diseases through modulation of the gut microflora. A nonsystematic review of the literature was performed, focusing on relevant trials evaluating the effect of probiotics/prebiotics/symbiotics in the prevention and treatment of allergic disease. For each allergic disease, we were able to find not only a substantial number of clinical trials but also systematic reviews. Specific guidelines, based on systematic reviews and meta-analyses, are available for the prevention of allergic disease and for the treatment of food allergy. In each of the areas examined-allergic rhinitis, allergic asthma, atopic dermatitis, food allergy, and gastrointestinal allergies-there are substantial uncertainties in the efficacy of gut microflora modulation in prevention and treatment. At present, practicing clinicians can avail themselves of intestinal flora modulators as an adjunct in the prevention of atopic dermatitis but not of other forms of allergic diseases. Their effects on the treatment of allergic diseases remain controversial.

Special Diets in Infants and Children and Impact on Gut Microbioma

Gut microbiota is a complex system that starts to take shape early in life. Several factors influence the rise of microbial gut colonization, such as term and mode of delivery, exposure to antibiotics, maternal diet, presence of siblings and family members, pets, genetics, local environment, and geographical location. Breastfeeding, complementary feeding, and later dietary patterns during infancy and toddlerhood are major players in the proper development of microbial communities. Nonetheless, if dysbiosis occurs, gut microbiota may remain impaired throughout life, leading to deleterious consequences, such as greater predisposition to non-communicable diseases, more susceptible immune system and altered gut-brain axis. Children with specific diseases (i.e., food allergies, inborn errors of metabolism, celiac disease) need a special formula and later a special diet, excluding certain foods or nutrients. We searched on PubMed/Medline, Scopus and Embase for relevant pediatric studies published over the last twenty years on gut microbiota dietary patterns and excluded case reports or series and letters. The aim of this review is to highlight the changes in the gut microbiota in infants and children fed with special formula or diets for therapeutic requirements and, its potential health implications, with respect to gut microbiota under standard diets.

Tolerance development in cow's milk-allergic infants receiving amino acid-based formula: A randomized controlled trial

BACKGROUND

Tolerance development is an important clinical outcome for infants with cow's milk allergy.

OBJECTIVE

This multicenter, prospective, randomized, double-blind, controlled clinical study (NTR3725) evaluated tolerance development to cow's milk (CM) and safety of an amino acid-based formula (AAF) including synbiotics (AAF-S) comprising prebiotic oligosaccharides (oligofructose, inulin) and probiotic Bifidobacterium breve M-16V in infants with confirmed IgE-mediated CM allergy.

METHODS

Subjects aged ≤13 months with IgE-mediated CM allergy were randomized to receive AAF-S (n = 80) or AAF (n = 89) for 12 months. Stratification was based on CM skin prick test wheal size and study site. After 12 and 24 months, CM tolerance was evaluated by double-blind, placebo-controlled food challenge. A logistic regression model used the all-subjects randomized data set.

RESULTS

At baseline, mean ± SD age was 9.36 ± 2.53 months. At 12 and 24 months, respectively, 49% and 62% of subjects were CM tolerant (AAF-S 45% and 64%; AAF 52% and 59%), and not differ significantly between groups. During the 12-month intervention, the number of subjects reporting at least 1 adverse event did not significantly differ between groups; however, fewer subjects required hospitalization due to serious adverse events categorized as infections in the AAF-S versus AAF group (9% vs 20%; P = .036).

CONCLUSIONS

After 12 and 24 months, CM tolerance was not different between groups and was in line with natural outgrowth. Results suggest that during the intervention, fewer subjects receiving AAF-S required hospitalization due to infections.

Early-Life Respiratory Infections in Infants with Cow's Milk Allergy: An Expert Opinion on the Available Evidence and Recommendations for Future Research

Acute respiratory infections are a common cause of morbidity in infants and young children. This high rate of respiratory infections in early life has a major impact on healthcare resources and antibiotic use, with the associated risk of increasing antibiotic resistance, changes in intestinal microbiota composition and activity and, consequently, on the future health of children. An international group of clinicians and researchers working in infant nutrition and cow's milk allergy (CMA) met to review the available evidence on the prevalence of infections in healthy infants and in those with allergies, particularly CMA; the factors that influence susceptibility to infection in early life; links between infant feeding, CMA and infection risk; and potential strategies to modulate the gut microbiota and infection outcomes. The increased susceptibility of infants with CMA to infections, and the reported potential benefits with prebiotics, probiotics and synbiotics with regard to improving infection outcomes and reducing antibiotic usage in infants with CMA, makes this a clinically important issue that merits further research.

Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy

ABSTRACT

Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them.

CONCLUSION

A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.

Bioactive Compounds in Food as a Current Therapeutic Approach to Maintain a Healthy Intestinal Epithelium

The intestinal epithelium serves as an effective barrier against the external environment, hampering the passage of potentially harmful substances (such as pathogenic microbes) that could trigger an exacerbated host immune response. The integrity of this barrier is thus essential for the maintenance of proper intestinal homeostasis and efficient protective reactions against chemical and microbial challenges. The principal consequence of intestinal barrier defects is an increase in intestinal permeability, which leads to an increased influx of luminal stressors, such as pathogens, toxins, and allergens, which in turn trigger inflammation and immune response. The fine and fragile balance of intestinal homeostasis can be altered by multiple factors that regulate barrier function, many of which are poorly understood. This review will address the role of gut microbiota as well as food supplements (such as probiotics, prebiotics, and synbiotics) in modulating gut health and regulating intestinal barrier function. In particular, we will focus on three human pathologies: inflammatory bowel disease, irritable bowel syndrome, and food allergy.

Growth in Infants with Cow's Milk Protein Allergy Fed an Amino Acid-Based Formula

PURPOSE

The present study assessed the role of an amino acid-based formula (AAF) in the growth of infants with cow's milk protein allergy (CMPA).

METHODS

Non-breastfed, term infants aged 0-6 months with symptoms suggestive of CMPA were recruited from 10 pediatric centers in China. After enrollment, infants were started on AAF for two weeks, followed by an open food challenge (OFC) with cow's milk-based formula (CMF). Infants with confirmed CMPA remained on AAF until 9 months of age, in conjunction with a cow's milk protein-free complementary diet. Body weight, length, and head circumference were measured at enrollment and 9 months of age. Measurements were converted to weight-for-age, length-for-age, and head circumference-for-age Z scores (WAZ, LAZ, HCAZ), based on the World Health Organization growth reference.

RESULTS

Of 254 infants (median age 16.1 weeks, 50.9% male), 218 (85.8%) were diagnosed with non-IgE-mediated CMPA, 33 (13.0%) tolerated CMF, and 3 (1.2%) did not complete the OFC. The mean WAZ decreased from 0.119 to -0.029 between birth and enrollment (p=0.067), with significant catch-up growth to 0.178 at 9 months of age (p=0.012) while being fed the AAF. There were no significant changes in LAZ (0.400 vs. 0.552; p=0.214) or HCAZ (-0.356 vs. -0.284; p=0.705) from the time of enrollment to age 9 months, suggesting normal linear and head growth velocity.

CONCLUSION

The amino acid-based study formula, in conjunction with a cow's milk protein-free complementary diet, supported normal growth till 9 months of age in a cohort of Chinese infants with challenge-confirmed non-IgE-mediated CMPA.

The Use of an Amino Acid Formula Containing Synbiotics in Infants with Cow's Milk Protein Allergy-Effect on Clinical Outcomes

Cow’s milk protein allergy (CMPA) is common and costly. Clinical trials of infants with CMPA have shown that the use of an amino acid formula containing pre- and probiotics (synbiotics) (AAF-Syn) may lead to significant reductions in infections, medication prescriptions and hospital admissions, compared to AAF without synbiotics. These effects have not yet been confirmed in real-world practice. This retrospective matched cohort study examined clinical and healthcare data from The Health Improvement Network database, from 148 infants with CMPA (54% male, mean age at diagnosis 4.69 months), prescribed either AAF-Syn (probiotic Bifidobacterium breve M16-V and prebiotics, including chicory-derived oligo-fructose and long-chain inulin) or AAF. AAF-Syn was associated with fewer symptoms (−37%, p < 0.001), infections (−35%, p < 0.001), medication prescriptions (−19%, p < 0.001) and healthcare contacts (−18%, p = 0.15) vs. AAF. Infants prescribed AAF-Syn had a significantly higher probability of achieving asymptomatic management without hypoallergenic formula (HAF) (adjusted HR 3.70, 95% CI 1.97–6.95, p < 0.001), with a shorter clinical course of symptoms (median time to asymptomatic management without HAF 1.35 years vs. 1.95 years). AAF-Syn was associated with potential cost-savings of £452.18 per infant over the clinical course of symptoms. These findings may be attributable to the effect of the specific synbiotic on the gut microbiome. Further research is warranted to explore this. This real-world study provides evidence consistent with clinical trials that AAF-Syn may produce clinical and healthcare benefits with potential economic impact.

Amino Acid Formula Containing Synbiotics in Infants with Cow's Milk Protein Allergy: A Systematic Review and Meta-Analysis

Cow's milk protein allergy (CMPA) is associated with dysbiosis of the infant gut microbiome, with allergic and immune development implications. Studies show benefits of combining synbiotics with hypoallergenic formulae, although evidence has never been systematically examined. This review identified seven publications of four randomised controlled trials comparing an amino acid formula (AAF) with an AAF containing synbiotics (AAF-Syn) in infants with CMPA (mean age 8.6 months; 68% male, mean intervention 27.3 weeks, n = 410). AAF and AAF-Syn were equally effective in managing allergic symptoms and promoting normal growth. Compared to AAF, significantly fewer infants fed AAF-Syn had infections (OR 0.35 (95% CI 0.19-0.67), p = 0.001). Overall medication use, including antibacterials and antifectives, was lower among infants fed AAF-Syn. Significantly fewer infants had hospital admissions with AAF-Syn compared to AAF (8.8% vs. 20.2%, p = 0.036; 56% reduction), leading to potential cost savings per infant of £164.05-£338.77. AAF-Syn was associated with increased bifidobacteria (difference in means 31.75, 95% CI 26.04-37.45, p < 0.0001); reduced Eubacterium rectale and Clostridium coccoides (difference in means -19.06, 95% CI -23.15 to -14.97, p < 0.0001); and reduced microbial diversity (p < 0.05), similar to that described in healthy breastfed infants, and may be associated with the improved clinical outcomes described. This review provides evidence that suggests combining synbiotics with AAF produces clinical benefits with potential economic implications.

EFSA Panel on Food Additives and Flavourings (FAF), Younes M, Aquilina G, Castle L, Engel K, Fowler P, Frutos Fernandez MJ, Fürst P, Gürtler R, Husøy T, Manco M, Mennes W, Moldeus P, Passamonti S, Shah R, Waalkens‐Berendsen I, Wölfle D, Wright M, Dusemund B, Mortensen A, Turck D, Barmaz S, Tard A, Vianello G, Gundert‐Remy U. Opinion on the re-evaluation of pectin (E 440i) and amidated pectin (E 440ii) as food additives in foods for infants below 16 weeks of age and follow-up of their re-evaluation as food additives for uses in foods for all population groups

Pectin (E 440i) and amidated pectin (E 440ii) were re-evaluated in 2017 by the former EFSA Panel on Food Additives and Nutrient sources added to Food (ANS). As a follow-up to this assessment, the Panel on Food Additives and Flavourings (FAF) was requested to assess the safety of pectins (E 440i,ii) for their uses as food additives in food for infants below 16 weeks of age. In addition, the FAF Panel was requested to address the issues already identified during the re-evaluation of the same food additive. The process involved the publication of a call for data to allow the interested business operators to provide the requested information to complete the risk assessment. Based on the information submitted in response to the call for data, the FAF Panel considered it feasible to amend the current specifications, in particular for the toxic elements arsenic, lead, cadmium, mercury and for sulfur dioxide and to introduce new specifications for aluminium and microbiological criteria. Studies on neonatal piglets, clinical studies and post-marketing data were made available during the call for data. Due to the low internal validity of the clinical studies, the Panel concluded that a reference point could not be derived from them, but the results of the adequate piglet study could serve to derive a reference point. When calculating the margin of safety for pectins exposure, this was below 1 for some scenarios. At the maximum permitted levels (MPLs), an internal methanol dose would be produced that could lead to adverse health effects in infants below 16 weeks of age. The FAF Panel recommended a reduction of the MPL of pectin (E 440i) and amidated pectin (E 440ii) in food categories 13.1.5.1 and 13.1.5.2, in order to reduce the exposure to both the additives themselves and to methanol.

Different elemental infant formulas show equivalent phosphorus and calcium bioavailability in healthy volunteers

Retrospective chart reviews have reported hypophosphatemia associated with elemental formula use in infants and children with systemic disease involving multiple diagnoses. The present study aims to evaluate the bioavailability of phosphorus from 2 commercial elemental formulas and to test our hypothesis of bioequivalence of the 2 products in healthy volunteers receiving gastric acid-suppressive medication. A single-center, double-blind, randomized, cross-over study was conducted in healthy volunteers with esomeprazole-induced hypochlorhydria. After a standardized low phosphorus meal followed by overnight fasting, subjects consumed 1 gram of phosphorus in a single oral dose of 1217 kcal of Product A (Neocate) or Product B (Elecare). The alternate product was given following a 1-week washout period. Blood and urine were collected at baseline and different time-points for up to 6 hours after product consumption. Area-under-the-curve (AUC) and peak values (C_peak) for serum phosphate and calcium and urinary creatinine-corrected phosphate and calcium were assessed for bioequivalence of Products A and B. Results show that the geometric mean ratio (GMR) and 90% CI for serum phosphate were 1.041 (0.998-1.086) and 1.020 (0.963-1.080) for AUC_0-360 and C_peak, respectively, meeting the predetermined criteria for bioequivalence. Urinary creatinine-corrected phosphate followed a similar pattern after intake of Product A and B, but did not reach bioequivalence criteria (GMR: AUC_70-370 = 1.105 (0.918-1.330); C_peak = 1.182 (1.040-1.343)). Serum calcium concentrations (GMR: AUC_0-360 = 1.002 (0.996-1.009); C_peak = 0.991 (0.983-0.999)) and urinary creatinine-corrected calcium excretion (GMR: AUC_70-370 = 1.117 (1.023-1.219); C_peak = 1.157 (1.073-1.247)) demonstrated bioequivalence of the products. In conclusion, both elemental infant formulas showed equivalent serum phosphorus and calcium bioavailability in healthy volunteers even if combined with treatment with acid-suppressive medication.

A well-tolerated new amino acid-based formula for cow's milk allergy

Objectives

Infants with cow's milk allergy (CMA) are in need of a substitute formula up to 2 years. The are three requisites for a substitute of milk in CMA: tolerability, nutritional adequacy, and cost‐effectiveness. We evaluate here the tolerability of a new amino acid–based infant formula for the management of CMA.

Methods

In a phase III/IV prospective, multicentre, open‐label, international study, infants and children with immunoglobulin E‐mediated CMA were exposed to a diagnostic double‐blinded, placebo‐controlled food challenge with a new amino acid formula by Blemil Plus Elemental using Neocate as the placebo. If tolerant to it, the study formula was integrated into the patients’ usual daily diet for 7 days. Efficacy on day 7 was assessed in terms of symptoms associated with CMA, amount of formula consumed, nutritional and energy intake, and anthropometric data.

Results

Thirty children (17 M and 13 F; median age, 1.58; range, 0.08‐12.83 years) completed the open challenge and were able to consume the study formula for at least 7 days. No signs or symptoms of allergic reactions were recorded among children assuming either the test or the control formula, with a lower 95% one‐sided confidence interval for the proportion of subjects who did not experience allergic reactions above 90%. Sixteen patient under the age of two continued with the optional extension phase.

Conclusions

The study formula meets the American Academy of Pediatric criteria for hypoallergenicity and is well tolerated in short‐term use. During optional phase, growth of the patients was not hindered by the study formula.

Food allergy and the microbiome: Current understandings and future directions

Growing evidence points to an important role for the commensal microbiota in susceptibility to food allergy. Epidemiologic studies demonstrate associations between exposures known to modify the microbiome and risk of food allergy. Direct profiling of the gut microbiome in human cohort studies has demonstrated that individuals with food allergy have distinct gut microbiomes compared to healthy control subjects, and dysbiosis precedes the development of food allergy. Mechanistic studies in mouse models of food allergy have confirmed that the composition of the intestinal microbiota can imprint susceptibility or resistance to food allergy on the host and have identified a unique population of microbially responsive RORγt-positive FOXp3-positive regulatory T cells as critical for the maintenance of tolerance to foods. Armed with this new understanding of the role of the microbiota in food allergy and tolerance, therapeutics aimed at modifying the gastrointestinal microbiota are in development. In this article we review key milestones in the development of our current understanding of how the gastrointestinal microbiota contributes to food allergy and discuss our vision for the future of the field.

Postbiotics and Their Potential Applications in Early Life Nutrition and Beyond

Postbiotics are functional bioactive compounds, generated in a matrix during fermentation, which may be used to promote health. The term postbiotics can be regarded as an umbrella term for all synonyms and related terms of these microbial fermentation components. Therefore, postbiotics can include many different constituents including metabolites, short-chain fatty acids (SCFAs), microbial cell fractions, functional proteins, extracellular polysaccharides (EPS), cell lysates, teichoic acid, peptidoglycan-derived muropeptides and pili-type structures. Postbiotics is also a rather new term in the '-biotics' field. Where consensus exists for the definitions of pre- and probiotics, this is not yet the case for postbiotics. Here we propose a working definition and review currently known postbiotic compounds, their proposed mechanisms, clinical evidence and potential applications. Research to date indicates that postbiotics can have direct immunomodulatory and clinically relevant effects and evidence can be found for the use of postbiotics in healthy individuals to improve overall health and to relief symptoms in a range of diseases such as infant colic and in adults atopic dermatitis and different causes of diarrhea.

Probiotics for cow's milk protein allergy: a systematic review of randomized controlled trials

Cow's milk protein allergy (CMPA) is the commonest food allergy in infancy and is associated with significant health burden. Given their immune modulatory properties, probiotics have been proposed as a strategy for management of CMPA. We aimed to systematically review efficacy and safety of probiotics in the management of CMPA. Databases PubMed, EMBASE, CINAHL, Cochrane Central Library, and Google scholar were searched in August 2018 for randomized controlled trials (RCT) of probiotic supplementation as an adjunct in the management of infants with suspected/proven CMPA. Primary outcomes were resolution of hematochezia and acquisition of tolerance to CMP at 6, 12, 24, and 36 months. Secondary outcomes included effect on allergic symptoms (SCORAD index), growth, gut microbiota, and adverse effects. A total of 10 RCTs (n = 845; probiotics, 422; control, 423) with low to unclear risk of bias were included. Meta-analysis showed probiotic supplementation was not associated with earlier resolution of hematochezia (n = 87; RR: 1.45 (95% CI: 0.96-2.18), p = 0.08; level of evidence (LOE), very low), in presumed CMPA. In confirmed CMPA, probiotics were associated with higher rate of acquisition of tolerance to CMP at the end of 3 years compared with placebo (N = 493; RR, 1.47; 95% CI, (1.17-1.84); p = 0.0009; LOE, low]. Meta-analysis was not possible for other outcomes. There were no probiotic related adverse effects. Conclusion: Limited low-quality evidence indicates that probiotic supplementation may be associated with earlier acquisition of tolerance to CMP in children with CMPA. Large well-designed trials are essential to confirm these findings. What is Known: • Cow's milk protein allergy (CMPA) is one of the commonest food allergies in children. CMPA is associated with significant socioeconomic burden. • Elimination diet and extensively hydrolyzed formula is the mainstay of the management of CMPA. What is New: • This first systematic review of randomized controlled trials shows that probiotics as an adjuvant can lead to earlier acquisition of tolerance to CMP in children at 36 months of age. However, the evidence is low quality and influenced by data from one large study. • Probiotic supplementation was not associated with earlier resolution of hematochezia.

A specific synbiotic-containing amino acid-based formula restores gut microbiota in non-IgE mediated cow's milk allergic infants: a randomized controlled trial

BACKGROUND

Altered gut microbiota is implicated in cow's milk allergy (CMA) and differs markedly from healthy, breastfed infants. Infants who suffer from severe CMA often rely on cow's milk protein avoidance and, when breastfeeding is not possible, on specialised infant formulas such as amino-acid based formulas (AAF). Herein, we report the effects of an AAF including specific synbiotics on oral and gastrointestinal microbiota of infants with non-IgE mediated CMA with reference to healthy, breastfed infants.

METHODS

In this prospective, randomized, double-blind controlled study, infants with suspected non-IgE mediated CMA received test or control formula. Test formula was AAF with synbiotics (prebiotic fructo-oligosaccharides and probiotic Bifidobacterium breve M-16V). Control formula was AAF without synbiotics. Healthy, breastfed infants were used as a separate reference group (HBR). Bacterial compositions of faecal and salivary samples were analysed by 16S rRNA-gene sequencing. Faecal analysis was complemented with the analysis of pH, short-chain fatty acids (SCFAs) and lactic acids.

RESULTS

The trial included 35 test subjects, 36 controls, and 51 HBR. The 16S rRNA-gene sequencing revealed moderate effects of test formula on oral microbiota. In contrast, the gut microbiota was substantially affected across time comparing test with control. In both groups bacterial diversity increased over time but was characterised by a more gradual increment in test compared to control. Compositionally this reflected an enhancement of Bifidobacterium spp. and Veillonella sp. in the test group. In contrast, the control-fed infants showed increased abundance of adult-like species, mainly within the Lachnospiraceae family, as well as within the Ruminococcus and Alistipes genus. The effects on Bifidobacterium spp. and Lachnospiraceae spp. were previously confirmed through enumeration by fluorescent in situ hybridization and were shown for test to approximate the proportions observed in the HBR. Additionally, microbial activity was affected as evidenced by an increase of l-lactate, a decrease of valerate, and reduced concentrations of branched-chain SCFAs in test versus control.

CONCLUSIONS

The AAF including specific synbiotics effectively modulates the gut microbiota and its metabolic activity in non-IgE mediated CMA infants bringing it close to a healthy breastfed profile.Trial registration Registered on 1 May 2013 with Netherlands Trial Register Number NTR3979.

The gut microbiome in food allergy

OBJECTIVE

To review observational human, murine, and interventional trial studies that have examined the gut microbiome in food allergy, and to provide perspective on future investigations in this field.

DATA SOURCES

A review of the published literature was performed with PubMed, and clinical studies catalogued at ClinicalTrials.gov were also reviewed.

STUDY SELECTIONS

The most recent relevant studies, seminal works, and topical clinical trials were selected.

RESULTS

Gut dysbiosis likely precedes the development of food allergy, and the timing of such dysbiosis is critical. Gut microbiota associated with individual food allergies may be distinct. Murine models support the importance of gut microbiota in shaping immune maturation and tolerance. Gut microbiota may affect food allergy susceptibility by modulating type 2 immunity, influencing immune development and tolerance, regulating basophil populations, and promoting intestinal barrier function. Ongoing and future interventional trials of probiotics, prebiotics, synbiotics, and fecal microbiota transfer will help translate our understanding of the gut microbiome in food allergy to clinical practice. Future work in this area will include deepening of current research foci, as well as expansion of efforts to include the virome, mycobiome, and interactions between the microbiome, host, and environment. Robust and consistent study designs, multidimensional profiling, and systems biology approaches will enable this future work.

CONCLUSION

By advancing research on the microbiome in food allergy, we can further our understanding of food allergy and derive new approaches for its prevention and therapy.

Letter to the Editor Re: Borschel M., et al. Comparison of Growth of Healthy Term Infants Fed Extensively Hydrolyzed Protein- and Amino Acid-Based Infant Formulas. Nutrients 2018, 10, 289

We read with interest the recently published narrative review of seven growth studies in healthy infants fed extensively hydrolyzed protein-based formulas (eHF) and amino acid-based formulas (AAF) [...].

Butyrate Enhances Desensitization Induced by Oral Immunotherapy in Cow's Milk Allergic Mice

Background

In previous studies, we showed that a fructo-oligosaccharide- (FOS-) supplemented diet enhanced oral immunotherapy (OIT) efficacy in a mouse model for cow's milk allergy. Fermentation of FOS by intestinal bacteria leads to production of short-chain fatty acids (SCFA) including butyrate.

Aim

To investigate the contribution of butyrate in the enhanced efficacy of OIT + FOS.

Methods

C3H/HeOuJ mice were sensitized and received OIT with or without FOS or butyrate supplementation. After treatment, whole blood was collected to conduct a basophil activation test (BAT) and allergen challenges were performed to measure acute allergic symptoms. CD4 + CD25 + regulatory T cells (Tregs) were isolated from treated mice or differentiated in vitro and used in a bone marrow-derived mast cell (BMMC) suppression assay. Cecum content was collected to analyze SCFA concentrations.

Results

Allergen-induced basophil activation was reduced in OIT + butyrate samples compared to OIT. Accordingly, the acute allergic skin response and mast cell degranulation upon challenge were reduced in OIT + butyrate and OIT + FOS mice compared to sensitized controls. Butyrate was increased in the cecum content of OIT + FOS mice compared to OIT mice and sensitized controls. Treg-mediated BMMC suppression was enhanced after in vivo butyrate and FOS exposure in combination with OIT but with a more pronounced effect for butyrate.

Conclusion

Butyrate supplementation enhanced OIT-induced desensitization of basophils and mast cells and Treg functionality. Only OIT + FOS treatment induced potential microbial alterations, shown by increased butyrate levels in cecum content. Both butyrate and FOS are promising candidates to improve OIT efficacy in human studies to treat food allergies.

A specific synbiotic-containing amino acid-based formula in dietary management of cow's milk allergy: a randomized controlled trial

BACKGROUND

Here we report follow-up data from a double-blind, randomized, controlled multicenter trial, which investigated fecal microbiota changes with a new amino acid-based formula (AAF) including synbiotics in infants with non-immunoglobulin E (IgE)-mediated cow's milk allergy (CMA).

METHODS

Subjects were randomized to receive test product (AAF including fructo-oligosaccharides and Bifidobacterium breve M-16V) or control product (AAF) for 8 weeks, after which infants could continue study product until 26 weeks. Fecal percentages of bifidobacteria and Eubacterium rectale/Clostridium coccoides group (ER/CC) were assessed at 0, 8, 12, and 26 weeks. Additional endpoints included stool markers of gut immune status, clinical symptoms, and safety assessments including adverse events and medication use.

RESULTS

The trial included 35 test subjects, 36 controls, and 51 in the healthy reference group. Study product was continued by 86% and 92% of test and control subjects between week 8-12, and by 71% and 80%, respectively until week 26. At week 26 median percentages of bifidobacteria were significantly higher in test than control [47.0% vs. 11.8% (p < 0.001)], whereas percentages of ER/CC were significantly lower [(13.7% vs. 23.6% (p = 0.003)]. Safety parameters were similar between groups. Interestingly use of dermatological medication and reported ear infections were lower in test versus control, p = 0.019 and 0.011, respectively. Baseline clinical symptoms and stool markers were mild (but persistent) and low, respectively. Symptoms reduced towards lowest score in both groups.

CONCLUSION

Beneficial effects of this AAF including specific synbiotics on microbiota composition were observed over 26 weeks, and shown suitable for dietary management of infants with non-IgE-mediated CMA.Trial Registration NTR3979.

Probiotics as treatment for food allergies among pediatric patients: a meta-analysis

Background

The burden of disease of food allergy is increasing worldwide. The standard of management is allergen avoidance and symptomatic treatment. Probiotics have been proposed to be beneficial for treatment and prevention of food allergy.

Objective

To determine the effectiveness of probiotic administration in treating food allergies among pediatric patients.

Methods

A systematic search of electronic medical literature databases was conducted. Manual search of the reference lists and search for unpublished articles were also done. All randomized controlled trials available from inception until February 19, 2018 were retrieved. The primary outcome of interest was relief of allergic symptoms, while the secondary outcome of interest was inducement of tolerance. Two independent authors did the search, screening, appraisal, and data abstraction. Data analysis and synthesis were done using RevMan 5.3 software. Subgroup analysis was done based on the probiotic strains and time periods in measuring the outcome. Exclusion sensitivity analysis was also done.

Results

Nine trials involving 895 pediatric patients with cow’s milk allergy (CMA) were included in the review. The primary outcome of interest, relief of symptoms, was measured using the scoring index for eczema. Pooled results from two studies showed larger reduction in the scoring index among patients given probiotics, but this effect was imprecise (MD -1.30, 95% CI -3.88, 1.28). For the secondary outcome of interest, pooled results from four studies showed benefit of probiotics in inducing tolerance, but again this result is imprecise with significant heterogeneity (RR 0.58, 95% CI 0.34, 1.00). Subgroup analysis per probiotic strain showed benefit of Lactobacillus rhamnosus GG in inducing tolerance based on two studies involving infants with suspected cow’s milk allergy (RR = 0.41, 95% CI 0.28 to 0.62). Another subgroup analysis showed a duration-dependent effect associated with probiotic usage, with inducement of tolerance noted after at least 2 years (RR = 0.44, 95% CI 0.29 to 0.67).

Conclusion

Analysis of available evidence shows moderate certainty that the use of probiotics can relieve symptoms of children with cow’s milk allergy. The reduction in certainty is due to imprecise results. Moreover, there is low certainty that probiotics can induce tolerance among children with cow’s milk allergy, due to problems of imprecision and attrition bias. In the subgroup analysis, Lactobacillus rhamnosus GG administration likely results in inducing tolerance among infants with suspected cow’s milk allergy. Only studies on CMA were analyzed since no studies were found on probiotics as treatment for other types of food allergy among children.

Electronic supplementary material

The online version of this article (10.1186/s40413-018-0204-5) contains supplementary material, which is available to authorized users.

Children with cow's milk allergy following an elimination diet had normal growth but relatively low plasma leptin at age two

AIM

To assess nutrient intake, growth and nutritional status of infants with cow's milk allergy (CMA) who follow a therapeutic elimination diet since the first few months of life.

METHODS

Sixty infants younger than four months of age with challenge-proven CMA and 60 healthy age-matched children were investigated. Anthropometric and body composition (BC) were assessed up to 24 months. Dietary intake was recorded by the parents for three consecutive days before visits at 6, 12, 18 and 24 months. Blood albumin, prealbumin, retinol binding protein and metabolic-related hormones were examined at 24 months.

RESULTS

The average age at enrolment was 2.9 ± 1.0 months. At the end of the follow-up, there were no differences in daily milk consumption, nutrient intake, weight and height z scores or BC measures between the groups; however, the plasma leptin level was lower in infants with CMA (1.67 ± 1.03 vs 2.05 ± 1.48) (ng/mL) (p < 0.05) compared to healthy children.

CONCLUSIONS

Children with CMA who followed an elimination diet could achieve a normal nutritional status, except for relatively lower plasma leptin levels, at the age of 2. Further studies with larger cohorts and research on the long-term consequences of these early differences are needed.

Hydrolyzed Formula With Reduced Protein Content Supports Adequate Growth: A Randomized Controlled Noninferiority Trial

OBJECTIVE

A high protein content of nonhydrolyzed infant formula exceeding metabolic requirements can induce rapid weight gain and obesity. Hydrolyzed formula with too low protein (LP) content may result in inadequate growth. The aim of this study was to investigate noninferiority of partial and extensively hydrolyzed formulas (pHF, eHF) with lower hydrolyzed protein content than conventionally, regularly used formulas, with or without synbiotics for normal growth of healthy term infants.

METHODS

In an European multi-center, parallel, prospective, controlled, double-blind trial, 402 formula-fed infants were randomly assigned to four groups: LP-formulas (1.9 g protein/100 kcal) as pHF with or without synbiotics, LP-eHF formula with synbiotics, or regular protein eHF (2.3 g protein/100 kcal). One hundred and one breast-fed infants served as observational reference group. As primary endpoint, noninferiority of daily weight gain during the first 4 months of life was investigated comparing the LP-group to a regular protein eHF group.

RESULTS

A comparison of daily weight gain in infants receiving LPpHF (2.15 g/day CI -0.18 to inf.) with infants receiving regular protein eHF showed noninferior weight gain (-3.5 g/day margin; per protocol [PP] population). Noninferiority was also confirmed for the other tested LP formulas. Likewise, analysis of metabolic parameters and plasma amino acid concentrations demonstrated a safe and balanced nutritional composition. Energetic efficiency for growth (weight) was slightly higher in LPeHF and synbiotics compared with LPpHF and synbiotics.

CONCLUSIONS

All tested hydrolyzed LP formulas allowed normal weight gain without being inferior to regular protein eHF in the first 4 months of life. This trial was registered at clinicaltrials.gov, NCT01143233.

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.

A synbiotic-containing amino-acid-based formula improves gut microbiota in non-IgE-mediated allergic infants

BackgroundPrebiotics and probiotics (synbiotics) can modify gut microbiota and have potential in allergy management when combined with amino-acid-based formula (AAF) for infants with cow's milk allergy (CMA).MethodsThis multicenter, double-blind, randomized controlled trial investigated the effects of an AAF-including synbiotic blend on percentages of bifidobacteria and Eubacterium rectale/Clostridium coccoides group (ER/CC) in feces from infants with suspected non-IgE-mediated CMA. Feces from age-matched healthy breastfed infants were used as reference (healthy breastfed reference (HBR)) for primary outcomes. The CMA subjects were randomized and received test or control formula for 8 weeks. Test formula was a hypoallergenic, nutritionally complete AAF including a prebiotic blend of fructo-oligosaccharides and the probiotic strain Bifidobacterium breve M-16V. Control formula was AAF without synbiotics.ResultsA total of 35 (test) and 36 (control) subjects were randomized; HBR included 51 infants. At week 8, the median percentage of bifidobacteria was higher in the test group than in the control group (35.4% vs. 9.7%, respectively; P<0.001), whereas ER/CC was lower (9.5% vs. 24.2%, respectively; P<0.001). HBR levels of bifidobacteria and ER/CC were 55% and 6.5%, respectively.ConclusionAAF including specific synbiotics, which results in levels of bifidobacteria and ER/CC approximating levels in the HBR group, improves the fecal microbiota of infants with suspected non-IgE-mediated CMA.

Dietary Intervention with β-Lactoglobulin-Derived Peptides and a Specific Mixture of Fructo-Oligosaccharides and Bifidobacterium breve M-16V Facilitates the Prevention of Whey-Induced Allergy in Mice by Supporting a Tolerance-Prone Immune Environment

Cow's milk allergy (CMA) prevails in infants and brings increased risk of developing other allergic diseases. Oral administration of specific β-lactoglobulin (BLG)-derived peptides (PepMix) and a specific blend of short- and long-chain fructo-oligosaccharides and Bifidobacterium breve M-16V (FF/Bb) was found to partially prevent CMA development in mice. In this study, we aimed to expand the knowledge on the preventive potential and the underlying mechanisms of this approach. Three-week-old female C3H/HeOuJ mice were orally exposed to PepMix±FF/Bb prior to a 5-week oral sensitization with whole whey and cholera toxin as an adjuvant. The acute allergic skin response was determined after an intradermal challenge with whole whey protein. Following an oral challenge with whey, regulatory T cells (T_regs) in the small intestine lamina propria (SI-LP) and mRNA expression of immune markers in the Peyer's patches (PP) were investigated. The early impact of PepMix and FF/Bb interventions on the immune system during the oral tolerance (OT) induction phase was investigated after the last OT administration. Pre-exposing mice to PepMix+FF/Bb partially prevented the acute allergic skin response compared to PBS and increased T_regs and activated T cells in the SI-LP compared to sham-sensitized mice. It also increased the mRNA expression of Tbet over GATA3 in the PP of whey-sensitized mice. Directly upon the 6-day OT phase, FF/Bb intervention enhanced cecal content levels of propionic and butyric acid in PepMix-fed mice and the former was positively correlated with Foxp3⁺ cell numbers in the colon. In the PP of PepMix+FF/Bb-exposed mice, IL-22 mRNA expression increased and IL-10 followed the same tendency, while the Foxp3 expression was increased over GATA3 and RorγT. In the colon, the Tbet mRNA expression increased over GATA3, while IL-22 decreased. In addition, the Foxp3⁺/GATA3⁺ and regulatory/effector T cell ratios in the mesenteric lymph nodes and the CD11b⁺/CD11b^- conventional dendritic cells ratio in the SI-LP were increased. In conclusion, the FF/Bb diet facilitates the capacity of the specific BLG-peptides to partially prevent the allergic response after sensitization to whole whey protein, possibly by creating a tolerance-prone environment during the OT phase. Such a dietary intervention might contribute to tailoring successful strategies for CMA prevention.

An interpretation of the new international MAP guideline for the management of Milk Allergy in Primary Care

General Practitioners suffer from guideline fatigue. They come fast and furious in many complicated forms. Cow's milk allergy (CMA) is one of the most common presentations of food allergy seen in early childhood presenting to primary and secondary care. The early and accurate diagnosis continues to be highlighted in many countries worldwide. International surveys have found that primary care clinicians would like clearer explanations for the options for the diagnosis of CMA and in so doing a means to increase their understanding of management options for both IgE and Non IgE mediated CMA. In 2013 in response to General Practitioner demands, the UK guideline, 'Diagnosis and management of non-IgE-mediated CMA in infancy-a UK primary care practical guide' was published in this journal. This Milk Allergy in Primary Care (MAP) guideline outlines in simple algorithmic form how to diagnose, manage and refer children with CMA in a primary care setting. Based on the international uptake of the MAP guideline, a global practical guideline International MAP is presented by the Venter and Brown et al to help practitioners in primary care settings. It incorporates further published UK guidance, feedback from UK healthcare professionals and affected families and, importantly, also international guidance and expertise.

Mineral Intake and Status of Cow's Milk Allergic Infants Consuming an Amino Acid-based Formula

Data on the mineral status of infants with cow's milk allergy (CMA) consuming an amino acid-based formula (AAF) have not been published. The present study aims to assess mineral status of term infants age 0 to 8 months diagnosed with CMA receiving an AAF for 16 weeks. Serum concentrations of calcium, phosphorus, chloride, sodium, potassium, magnesium, and ferritin were determined in 82 subjects at baseline and in 66 subjects after 16 weeks on AAF using standard methods and evaluated against age-specific reference ranges. In addition to this, individual estimated energy and mineral intakes were compared to Adequate Intakes defined by the European Food Safety Authority and the US Institute of Medicine. The results of this study show that the AAF was effective in providing an adequate mineral status in infants with CMA. The vast majority of infants aged 0 to 6 months (formula only) and aged 6 to 12 months (formula and complementary foods) had adequate mineral intakes.

A Specific Mixture of Fructo-Oligosaccharides and Bifidobacterium breve M-16V Facilitates Partial Non-Responsiveness to Whey Protein in Mice Orally Exposed to β-Lactoglobulin-Derived Peptides

Oral tolerance is a promising approach for allergy prevention in early life, but it strongly depends on allergen exposure and proper immune environment. Small tolerance-inducing peptides and dietary immunomodulatory components may comprise an attractive method for allergy prevention in at-risk infants. This study aimed to investigate whether early oral exposure to β-lactoglobulin-derived peptides (BLG-peptides) and a specific synbiotic mixture of short- and long- chain fructo-oligosaccharides (scFOS/lcFOS, FF) and Bifidobacterium breve (Bb) M-16V (FF/Bb) can prevent cow’s milk allergy (CMA). Three-week-old female C3H/HeOuJ mice were orally exposed to phosphate buffered saline (PBS), whey protein, or a mixture of four synthetic BLG-peptides combined with a FF/Bb-enriched diet prior to intragastric sensitization with whey protein and cholera toxin. To assess the acute allergic skin response and clinical signs of allergy, mice were challenged intradermally with whole whey protein. Serum immunoglobulins were analyzed after a whey protein oral challenge. Cytokine production by allergen-reactivated splenocytes was measured and changes in T cells subsets in the spleen, mesenteric lymph nodes, and intestinal lamina propria were investigated. Pre-exposing mice to a low dosage of BLG-peptides and a FF/Bb-enriched diet prior to whey protein sensitization resulted in a significant reduction of the acute allergic skin response to whey compared to PBS-pretreated mice fed a control diet. Serum immunoglobulins were not affected, but anaphylactic symptom scores remained low and splenocytes were non-responsive in whey-induced cytokine production. In addition, preservation of the T_h1/T_h2 balance in the small intestine lamina propria was a hallmark of the mechanism underlying the protective effect of the BLG-peptides–FF/Bb intervention. Prior exposure to BLG-peptides and a FF/Bb-enriched diet is a promising approach for protecting the intestinal T_h1/T_h2 balance and reducing the allergic response to whole whey protein. Therefore, it might have implications for developing successful nutritional strategies for CMA prevention.

Treatment of allergic children - Where is the progress (for the practicing allergist)?

For any kind of therapeutic intervention in allergic diseases such as environmental control, pharmacological, or immunomodulating treatment including educational programs, children are addressed separately from adults. Health authorities like the Food and Drug Administration in the United States of America or the European Medicine Agency in Europe request a specific 'Pediatric investigational plan' with studies addressing dose-response relationship, safety, and efficacy for infants, children, and adolescents. During the last 2 years, promising advances have been reported for the treatment of a variety of allergic and immunologic disorders. This review summarizes the progress in the treatment of pediatric asthma and allergic diseases, based on publications of approximately the last 2.5 years (end of 2013 until May 2016) in and beyond this journal. Meanwhile, it highlights areas with promising novel therapeutic approaches, which are likely to change treatment for allergic children in the near future.

Post-sensitization administration of non-digestible oligosaccharides and Bifidobacterium breve M-16V reduces allergic symptoms in mice

To support dietary management of severe cow's milk allergic infants, a synbiotic mixture of non-digestible oligosaccharides and Bifidobacterium breve M-16V (B. breve) was designed from source materials that are completely cow's milk-free. It was investigated whether this specific synbiotic concept can reduce an established food allergic response in a research model for hen's egg allergy. Mice were orally sensitized once a week for 5 weeks to ovalbumin (OVA) using cholera toxin (CT) as an adjuvant. Non-sensitized mice received CT in PBS only. Sensitized mice were fed a control diet or a diet enriched with short-chain- (scFOS) and long-chain fructo-oligosaccharides (lcFOS), B. breve or scFOSlcFOS + B. breve for 3 weeks starting after the last sensitization. Non-sensitized mice received the control diet. Anaphylactic shock symptoms, acute allergic skin responses and serum specific IgE, mMCP-1 and galectin-9 were measured upon OVA challenge. Activated Th2-, Th1-cells and regulatory T-cells were quantified in spleen and mesenteric lymph nodes (MLN) and cytokine profiles were analyzed. Short chain fatty acids (SCFA) were measured in ceacal samples. The acute allergic skin response was reduced in mice fed the scFOSlcFOS + B. breve diet compared to mice fed any of the other diets. A reduction in mast cell degranulation (mMCP-1) and anaphylactic shock symptoms was also observed in these mice. Unstimulated splenocyte cultures produced increased levels of IL10 and IFNg in mice fed the scFOSlcFOS + B. breve diet. Correspondingly, increased percentages of activated Th1 cells were observed in the spleen. Allergen-specific re-stimulation of splenocytes showed a decrease in IL5 production. In summary; post-sensitization administration of scFOSlcFOS + B. breve was effective in reducing allergic symptoms after allergen challenge. These effects coincided with changes in regulatory and effector T-cell subsets and increases in the SCFA propionic acid. These results suggest immune modulatory benefits of dietary intervention with a unique combination of scFOSlcFOS + B. breve in established food allergy. Whether these effects translate to human applications is subject for ongoing clinical studies.