"Frequency of fatal and recurrent anaphylaxis due to COW'S milk: A systematic review and meta-analysis of observational studies"

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term comparison of high- and low-dose oral immunotherapy in children with anaphylactic cow's milk allergy

BACKGROUND

Long-term evidence on maintenance doses of oral immunotherapy (OIT) for anaphylactic cow's milk allergy is insufficient.

METHODS

We retrospectively compared the three-year safety, efficacy, and adherence between OIT with a maintenance dose of 200 mL of cow's milk (HOIT, 2009-2013) and 3 mL of cow's milk (LOIT, 2013-2019). Patients aged 6-18 years with a history of anaphylaxis reacting to ≤3 mL of cow's milk during oral food challenge (OFC) were included. Adverse symptoms, OFC negative rate after 2 weeks of avoidance, dropout rate, and immunological changes were compared.

RESULTS

The median ages in the HOIT (n = 78) and LOIT (n = 99) groups were 8.1 and 7.8 years, with milk-specific IgE levels of 56.5 and 49.2 kUA/L, respectively. The percentages of doses triggering symptoms were 20.88%, 13.73%, and 7.31% in the HOIT group and 11.81%, 8.15%, and 6.30% in the LOIT group during years 1, 2, and 3, respectively. After 3 years, 29% of patients in the HOIT group passed the OFC with 200 mL, and 47%, 18%, and 5% of patients in the LOIT group passed the OFC with ≥25 mL, ≥50 mL, and 100 mL of cow's milk, respectively. After 3 years, the dropout rates were 24% and 11% in the HOIT and LOIT groups and milk-specific IgE levels decreased by 88% and 78% in the HOIT and LOIT groups, respectively.

CONCLUSION

HOIT enables higher dose consumptions. LOIT might be safer and have higher adherence in patients with anaphylactic cow's milk allergy.

The journey toward disease modification in cow milk protein allergy

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

Dietary Advancement Therapy Using Milk and Egg Ladders Among Children With a History of Anaphylaxis

BACKGROUND

Anaphylaxis has been increasing in recent years, with common triggers in infants being milk and eggs. Currently, the mainstay of treatment for milk and/or egg allergy is strict avoidance. Recently, new therapies have emerged including stepwise introduction of allergens via a ladder approach. The suitability of infants for the ladders is debated.

OBJECTIVE

This study aims to focus on the use of food ladders in children with anaphylaxis to egg or milk.

METHODS

Retrospective review of pediatric patients diagnosed with immunoglobulin E-mediated milk and/or egg allergy between 2011 and 2021. Inclusion and exclusion criteria were applied. Anaphylaxis was defined as per the World Allergy Organization-amended criteria 2020. Data analysis utilized SPSS Version 28.

RESULTS

We reviewed 1,552 patient charts, and excluded 1,094, leaving a total sample size of 458. Seventy infants had anaphylaxis at diagnosis (milk n = 36; egg n = 34). A range of 77.8% to 85.2% of infants with anaphylaxis successfully completed the ladder, 88.9% to 92.9% without anaphylaxis were successful. Children who successfully completed the ladder did so at similar rates. A range of 20.6% to 50% children presenting with anaphylaxis at diagnosis experienced allergic symptoms during treatment, compared with 17.3% to 40.7% without anaphylaxis. Reactions were mild, mostly cutaneous and not requiring medical attention. Patients experiencing allergic symptoms while on the ladder were less likely to successfully complete treatment.

CONCLUSIONS

Milk and egg ladders are a safe and effective way of inducing tolerance in infants, including those with a history of anaphylaxis at diagnosis. There are no obvious predictors for who will experience allergic reactions while on the ladder; however, these children are less likely to complete the ladder, so parents should be educated in management of mild allergic reactions at home.

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

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