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Boulangé CL, Pedersen HK, Martin FP, Siegwald L, Pallejà Caro A, Eklund AC, Jia W, Zhang H, Berger B, Sprenger N, Heine RG, Cinnamon Study Investigator Group. An Extensively Hydrolyzed Formula Supplemented with Two Human Milk Oligosaccharides Modifies the Fecal Microbiome and Metabolome in Infants with Cow's Milk Protein Allergy. Int J Mol Sci 2023; 24:11422. [PMID: 37511184 PMCID: PMC10379726 DOI: 10.3390/ijms241411422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Cow's milk protein allergy (CMPA) is a prevalent food allergy among infants and young children. We conducted a randomized, multicenter intervention study involving 194 non-breastfed infants with CMPA until 12 months of age (clinical trial registration: NCT03085134). One exploratory objective was to assess the effects of a whey-based extensively hydrolyzed formula (EHF) supplemented with 2'-fucosyllactose (2'-FL) and lacto-N-neotetraose (LNnT) on the fecal microbiome and metabolome in this population. Thus, fecal samples were collected at baseline, 1 and 3 months from enrollment, as well as at 12 months of age. Human milk oligosaccharides (HMO) supplementation led to the enrichment of bifidobacteria in the gut microbiome and delayed the shift of the microbiome composition toward an adult-like pattern. We identified specific HMO-mediated changes in fecal amino acid degradation and bile acid conjugation, particularly in infants commencing the HMO-supplemented formula before the age of three months. Thus, HMO supplementation partially corrected the dysbiosis commonly observed in infants with CMPA. Further investigation is necessary to determine the clinical significance of these findings in terms of a reduced incidence of respiratory infections and other potential health benefits.
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Affiliation(s)
- Claire L Boulangé
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., 1000 Lausanne, Switzerland
| | | | - Francois-Pierre Martin
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., 1000 Lausanne, Switzerland
| | - Léa Siegwald
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., 1000 Lausanne, Switzerland
| | | | | | - Wei Jia
- University of Hawaii Cancer Center, Honolulu, HI 96813, USA
- School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong, Hong Kong 999077, China
| | - Huizhen Zhang
- University of Hawaii Cancer Center, Honolulu, HI 96813, USA
| | - Bernard Berger
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., 1000 Lausanne, Switzerland
| | - Norbert Sprenger
- Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., 1000 Lausanne, Switzerland
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Minor G, Sentongo T, Heine RG, Zemrani B. Tolerability and safety of a semi-elemental enteral formula with partially hydrolyzed guar gum (PHGG) in tube-fed children aged 1-4 years: An open-label, single-arm study. Clin Nutr ESPEN 2023; 55:392-399. [PMID: 37202073 DOI: 10.1016/j.clnesp.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND AIMS Partially hydrolyzed guar gum (PHGG) is a water-soluble fiber supporting digestive health with well-established safety and efficacy. This open-label, single-arm, multicenter trial aimed to assess the tolerability and safety of a semi-elemental enteral formula containing PHGG at 12 g/L in tube-fed young children. METHODS Children aged 1-4 years with stable conditions requiring tube feeding to provide ≥80% of their nutritional needs received the study formula for seven days. Tolerability, safety, adequacy of energy/protein intake, and weight change were assessed. RESULTS Of 24 children (mean age 33.5 months; 10 [41.7%] female), 23 (95.8%) commenced treatment and 18 (75%) completed the study. All children had underlying neuro-developmental disabilities, often in association with gastrointestinal comorbidities requiring treatment for constipation (70.8%) or gastroesophageal reflux (66.7%). The formula was well-tolerated by 19 (82.6%) subjects, while 4 (17.4%; 95% CI: 5%, 39%) subjects withdrew early from the study due to gastrointestinal intolerance. The mean (SD) percentage energy and protein intake across the 7-day period were 103.5% (24.7) and 139.5% [50], respectively. Weight remained stable over the 7-day period (p = 0.43). The study formula was associated with a shift towards softer and more frequent stools. Pre-existing constipation was generally well controlled, and 3/16 (18.7%) subjects ceased laxatives during the study. Adverse events were reported in 12 (52%) subjects and were deemed 'probably related' or 'related' to the formula in 3 (13%) subjects. Gastrointestinal adverse events appeared more common in fiber-naïve patients (p = 0.09). CONCLUSION The present study indicates that the study formula was safe and generally well tolerated in young tube-fed children. CLINICALTRIALS GOV IDENTIFIER NCT04516213.
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Affiliation(s)
- Gerard Minor
- Pediatric Gastroenterology, Hepatology & Nutrition, KIDZ Medical Services, Hollywood, FL, USA.
| | - Timothy Sentongo
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology & Nutrition, Comer Children's Hospital, University of Chicago, Chicago, IL, USA.
| | - Ralf G Heine
- Clinical Research and Development, Pediatric Medical Nutrition, Nestlé Health Science, Vevey, Switzerland.
| | - Boutaina Zemrani
- Clinical Research and Development, Pediatric Medical Nutrition, Nestlé Health Science, Vevey, Switzerland.
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Gold MS, Quinn PJ, Campbell DE, Peake J, Smart J, Robinson M, O’Sullivan M, Vogt JK, Pedersen HK, Liu X, Pazirandeh-Micol E, Heine RG. Effects of an Amino Acid-Based Formula Supplemented with Two Human Milk Oligosaccharides on Growth, Tolerability, Safety, and Gut Microbiome in Infants with Cow's Milk Protein Allergy. Nutrients 2022; 14:nu14112297. [PMID: 35684099 PMCID: PMC9182596 DOI: 10.3390/nu14112297] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 12/04/2022] Open
Abstract
This open-label, non-randomized, multicenter trial (Registration: NCT03661736) aimed to assess if an amino acid-based formula (AAF) supplemented with two human milk oligosaccharides (HMO) supports normal growth and is well tolerated in infants with a cow's milk protein allergy (CMPA). Term infants aged 1-8 months with moderate-to-severe CMPA were enrolled. The study formula was an AAF supplemented with 2'-fucosyllactose (2'-FL) and lacto-N-neotetraose (LNnT). Infants were fed the study formula for 4 months and were offered to remain on the formula until 12 months of age. Tolerance and safety were assessed throughout the trial. Out of 32 infants (mean age 18.6 weeks; 20 (62.5%) male), 29 completed the trial. During the 4-month principal study period, the mean weight-for-age Z score (WAZ) increased from -0.31 at the baseline to +0.28 at the 4-months' follow-up. Linear and head growth also progressed along the WHO child growth reference, with a similar small upward trend. The formula was well tolerated and had an excellent safety profile. When comparing the microbiome at the baseline to the subsequent visits, there was a significant on-treatment enrichment in HMO-utilizing bifidobacteria, which was associated with a significant increase in fecal short-chain fatty acids. In addition, we observed a significant reduction in the abundance of fecal Proteobacteria, suggesting that the HMO-supplemented study formula partially corrected the gut microbial dysbiosis in infants with CMPA.
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Affiliation(s)
- Michael S. Gold
- Department of Allergy & Immunology, Women’s and Children’s Hospital, University of Adelaide, Adelaide, SA 5006, Australia;
- Correspondence:
| | - Patrick J. Quinn
- Department of Allergy & Immunology, Women’s and Children’s Hospital, University of Adelaide, Adelaide, SA 5006, Australia;
| | - Dianne E. Campbell
- Department of Allergy & Clinical Immunology, Children’s Hospital at Westmead, University of Sydney, Sydney, NSW 2145, Australia;
| | - Jane Peake
- Queensland Paediatric Immunology and Allergy Service, Queensland Children’s Hospital, University of Queensland, South Brisbane, QLD 4101, Australia;
| | - Joanne Smart
- Paediatric Allergy Services, Epworth Hospital, Richmond, VIC 3121, Australia;
| | - Marnie Robinson
- Melbourne Allergy Centre & Children’s Specialists Medical Group, Parkville, VIC 3152, Australia;
| | - Michael O’Sullivan
- Department of Immunology, Perth Children’s Hospital, Nedlands, WA 6009, Australia
| | | | | | - Xiaoqiu Liu
- Biostatistics and Data Science Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW 2042, Australia;
| | | | - Ralf G. Heine
- Nestlé Health Science, CH-1800 Vevey, Switzerland; (E.P.-M.); (R.G.H.)
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Madrazo JA, Alrefaee F, Chakrabarty A, de Leon JC, Geng L, Gong S, Heine RG, Järvi A, Ngamphaiboon J, Ong C, Rogacion JM. International Cross-Sectional Survey among Healthcare Professionals on the Management of Cow's Milk Protein Allergy and Lactose Intolerance in Infants and Children. Pediatr Gastroenterol Hepatol Nutr 2022; 25:263-275. [PMID: 35611371 PMCID: PMC9110852 DOI: 10.5223/pghn.2022.25.3.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/22/2021] [Accepted: 03/07/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The present international survey among healthcare providers aimed to collect data on theoretical knowledge and clinical practices in the diagnosis and management of cow's milk protein allergy (CMPA) and lactose intolerance (LI) in infants. METHODS A global survey was conducted in several countries with diverse health care settings. The survey consisted of multiple-choice questions in 3 main domains: (1) understanding and clinical practices around CMPA and LI; (2) case scenarios; and (3) disease-specific knowledge and potential educational needs. RESULTS Responses were available from 1,663 participants. About 62% of respondents were general practitioners or general pediatricians, and the remainder were pediatric allergists/gastroenterologists (18%) or other health practitioners (20%). The survey identified knowledge gaps regarding the types of CMPA (IgE-mediated vs. non-IgE-mediated) and the clinical overlap with LI. The survey suggested diverse clinical practices regarding the use of hypoallergenic formulas, as well as misconceptions about the prebiotic benefits of lactose in extensively hydrolyzed formulas in non-breastfed infants with CMPA. Responses to the two case scenarios highlighted varying levels of awareness of the relevant clinical practice guidelines. While respondents generally felt confident in managing infants with CMPA and LI, about 80% expressed an interest for further training in this area. CONCLUSION The current survey identified some knowledge gaps and regional differences in the management of infants with CMPA or LI. Local educational activities among general and pediatric healthcare providers may increase the awareness of clinical practice guidelines for the diagnosis and treatment of both conditions and help improve clinical outcomes.
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Affiliation(s)
- J Armando Madrazo
- Department of Pediatrics, Universidad Nacional Autónoma de México, México City, México
| | - Fawaz Alrefaee
- Pediatric Department, Al Adan Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Anjan Chakrabarty
- Department of Paediatrics, West Middlesex University Hospital, Isleworth, United Kingdom
| | - Julia C de Leon
- Department of Pediatrics, Cardinal Santos Medical Center, Manila, Philippines
| | - Lanlan Geng
- Department of Gastroenterology, Guangzhou Women's and Children's Medical Center, Guangzhou, China
| | - Sitang Gong
- Department of Pediatrics, Guangzhou Women's and Children's Medical Center, Guangzhou, China
| | | | | | | | - Christina Ong
- Department of Paediatric Gastroenterology, KK Women's and Children's Hospital, Singapore
| | - Jossie M Rogacion
- Department of Pediatrics, University of the Philippines, Philippine General Hospital, Manila, Philippines
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Vandenplas Y, Zhao ZY, Mukherjee R, Dupont C, Eigenmann P, Kuitunen M, Ribes Koninckx C, Szajewska H, von Berg A, Bajerová K, Meyer R, Salvatore S, Shamir R, Järvi A, Heine RG. Assessment of the Cow's Milk-related Symptom Score (CoMiSS) as a diagnostic tool for cow's milk protein allergy: a prospective, multicentre study in China (MOSAIC study). BMJ Open 2022; 12:e056641. [PMID: 35177461 PMCID: PMC8860045 DOI: 10.1136/bmjopen-2021-056641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The MOSAIC study aimed to evaluate if the Cow's Milk-related Symptom Score (CoMiSS) can be used as a stand-alone diagnostic tool for cow's milk protein allergy (CMPA). DESIGN Single-blinded, prospective, multicentre diagnostic accuracy study. SETTING 10 paediatric centres in China. PARTICIPANTS 300 non-breastfed infants (median age 16.1 weeks) with suspected CMPA. INTERVENTIONS After performing the baseline CoMiSS, infants commenced a cow's milk protein elimination diet with amino acid-based formula for 14 days. CoMiSS was repeated at the end of the elimination trial. Infants then underwent an open oral food challenge (OFC) with cow's milk-based formula (CMF) in hospital. Infants who did not react during the OFC also completed a 14-day home challenge with CMF. A diagnosis of CMPA was made if acute or delayed reactions were reported. PRIMARY OUTCOME MEASURES A logistic regression model for CoMiSS to predict CMPA was fitted and a receiver-operator characteristic (ROC) curve generated. An area under the curve (AUC) of ≥0.75 was deemed adequate to validate CoMiSS as a diagnostic tool (target sensitivity 80%-90% and specificity 60%-70%). RESULTS Of 254 infants who commenced the OFC, 250 completed both challenges, and a diagnosis of CMPA made in 217 (85.4%). The median baseline CoMiSS in this group fell from 8 (IQR 5-10) to 5 (IQR 3-7) at visit 2 (p<0.000000001), with a median change of -3 (IQR -6 to -1). A baseline CoMiSS of ≥12 had a low sensitivity (20.3%), but high specificity (87.9%) and high positive predictive value (91.7%) for CMPA. The ROC analysis with an AUC of 0.67 fell short of the predefined primary endpoint. CONCLUSIONS The present study did not support the use of CoMiSS as a stand-alone diagnostic tool for CMPA. Nevertheless, CoMiSS remains a clinically useful awareness tool to help identify infants with cow's milk-related symptoms. TRIAL REGISTRATION NUMBER NCT03004729; Pre-results.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel, UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Zheng-Yan Zhao
- Children's Hospital Zhejiang, University School of Medicine, Zhejiang University, Hangzhou, China
| | | | - Christophe Dupont
- Department of Paediatrics, Hôpital Necker-Enfants Malades, Paris, France
| | - Philippe Eigenmann
- Department of Infants and Adolescents, University Hospitals Geneva, Geneva, Switzerland
| | - Mikael Kuitunen
- New Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Carmen Ribes Koninckx
- Paediatric Gastroenterology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Warszawa, Poland
| | - Andrea von Berg
- Research Institute, Department of Paediatrics, Marien-Hospital Wesel, Wesel, Germany
| | - Kateřina Bajerová
- Research Institute, Department of Paediatrics, Marien-Hospital Wesel, Wesel, Germany
| | - Rosan Meyer
- Department of Paediatrics, Imperial College London, London, UK
| | - Silvia Salvatore
- Department of Paediatrics, Hospital 'F. Del Ponte', University of Insubria, Varese, Italy
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Vandenplas Y, Dupont C, Eigenmann P, Heine RG, Høst A, Järvi A, Kuitunen M, Mukherjee R, Ribes-Koninckx C, Szajewska H, von Berg A, Zhao ZY. Growth in Infants with Cow's Milk Protein Allergy Fed an Amino Acid-Based Formula. Pediatr Gastroenterol Hepatol Nutr 2021; 24:392-402. [PMID: 34316474 PMCID: PMC8279827 DOI: 10.5223/pghn.2021.24.4.392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/15/2021] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Yvan Vandenplas
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Christophe Dupont
- Hôpital Necker-Enfants Malades, Université de Paris Descartes, Paris, France
| | - Philippe Eigenmann
- Paediatric Allergy Unit, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Arne Høst
- Department of Paediatrics, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | | | - Mikael Kuitunen
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | | | - Carmen Ribes-Koninckx
- Paediatric Gastroenterology and Hepatology Unit, La Fe University Hospital, Valencia, Spain
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | | | - Zheng-Yan Zhao
- Children's Hospital Zhejiang, University School of Medicine, Hangzhou, China
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Nutten S, Maynard F, Järvi A, Rytz A, Simons PJ, Heine RG, Kuslys M. Peptide size profile and residual immunogenic milk protein or peptide content in extensively hydrolyzed infant formulas. Allergy 2020; 75:1446-1449. [PMID: 31705686 PMCID: PMC7318342 DOI: 10.1111/all.14098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/27/2019] [Accepted: 10/12/2019] [Indexed: 12/20/2022]
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Nutten S, Schuh S, Dutter T, Heine RG, Kuslys M. Design, quality, safety and efficacy of extensively hydrolyzed formula for management of cow's milk protein allergy: What are the challenges? Adv Food Nutr Res 2020; 93:147-204. [PMID: 32711862 DOI: 10.1016/bs.afnr.2020.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Cow's milk protein allergy (CMPA) is one of the most common food allergies in infancy. Clinical food allergy guidelines recommend an extensively hydrolyzed formula (EHF) as the first-line treatment in nonbreastfed infants with CMPA. Designing and commercializing EHF poses both technical and regulatory challenges. Each manufacturing step, from sourcing of raw materials to release of the final product, needs to be managed in accordance with comprehensive quality systems. To avoid cross-contamination via externally sourced ingredients, suppliers should be carefully selected based on quality requirements. Strict zoning of the manufacturing areas according to contamination risk and air flow control are effective strategies to prevent accidental allergen contamination. Furthermore, dedicated manufacturing lines for hypoallergenic products are used to prevent potential cross-contamination from other products produced on the same line. The enzymatic hydrolysis, heat treatment and ultrafiltration used are specific to each manufacturer. Consequently, EHF are a heterogenous group of products with differences in the molecular weight profile of peptides, content of residual immunogenic cow's milk allergens, and residual in-vitro allergenicity. These differences are likely to affect clinical efficacy and safety. As not all commercialized EHF products have undergone formal testing in the laboratory and clinical trials, there is a need to develop guidelines for minimum technical and regulatory requirements for EHF products, including validated assays for ongoing quality control. Clinical trials assessing new EHF products for their hypoallergenicity and ability to support normal growth remain the definitive proof of efficacy and safety in infants and young children with CMPA.
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Affiliation(s)
| | - Susanne Schuh
- Nestlé Research and Development, Konolfingen, Switzerland
| | - Thibaut Dutter
- Nestlé Research and Development, Konolfingen, Switzerland
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Nowak‐Węgrzyn A, Czerkies L, Kuslys M, Nutten S, Simons PJ, Collins B, Heine RG. Hypoallergenicity of a whey-based, extensively hydrolyzed infant formula prepared with nonporcine enzymes. Allergy 2019; 74:1582-1584. [PMID: 30897220 DOI: 10.1111/all.13780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Anna Nowak‐Węgrzyn
- Mount Sinai Medical Centre, Icahn School of Medicine Jaffe Institute New York New York
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Heine RG, Peters R, Cameron DJ, Alex G, Oliver MR, Hardikar W, Chow CW, McWilliam VL, Moore DJ, Kakakios AM, Cheah E, O'Loughlin EV, Axelrad C, Allen K. Effect of a 4-Food Elimination Diet and Omeprazole in Children with Eosinophilic Esophagitis – A Randomized, Controlled Trial. J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Matta J, Alex G, Cameron DJS, Chow CW, Hardikar W, Heine RG. Pediatric Collagenous Gastritis and Colitis: A Case Series and Review of the Literature. J Pediatr Gastroenterol Nutr 2018; 67:328-334. [PMID: 29601434 DOI: 10.1097/mpg0000000000001975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands. Two phenotypes of the disease have been described: a pediatric-onset and an adult-onset type. The adult-onset form is associated with collagenous colitis and autoimmune disorders. No effective treatment has been identified to date. OBJECTIVE We aim to describe the clinical features and outcomes of patients in our cohort and provide a summary of published pediatric cases with collagenous gastritis and colitis reported to date to gather information that will contribute to improved knowledge of this rare condition. METHODS A retrospective chart review of all patients with collagenous gastritis and/or colitis who were treated at the Royal Children's Hospital, Melbourne, was performed. A literature review was also conducted. RESULTS A total of 12 cases of collagenous gastritis were reviewed. Three of 12 (25%) patients had associated collagenous colitis. The most common clinical presentation was iron deficiency anemia. Nine (75%) patients were followed up, and repeat endoscopies were performed in 8 (67%). Iron deficiency anemia resolved in all patients on oral iron supplementation. Histologic improvement was only identified in one patient with the adult phenotype who had been treated with oral corticosteroids and azathioprine. CONCLUSIONS Collagenous gastritis is a rare condition in children. A small proportion of children develop features of the "'adult" phenotype at a very young age. Patients with collagenous gastritis require long-term follow-up and monitoring of their disease. Further randomized clinical trials are needed to establish an effective therapeutic strategy.
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Affiliation(s)
- Judy Matta
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia
- Department of Gastroenterology and Clinical Nutrition, Saint George Hospital University Medical Center
- Department of Pediatrics, University of Balamand, Beirut, Lebanon
| | - George Alex
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia
- Department of Pediatrics, University of Melbourne
| | - Donald J S Cameron
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute
| | - Chung W Chow
- Department of Pediatrics, University of Melbourne
- Department of Anatomical Pathology, The Royal Children's Hospital, Melbourne, Australia
| | - Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia
- Department of Pediatrics, University of Melbourne
- Murdoch Children's Research Institute
| | - Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia
- Department of Pediatrics, University of Melbourne
- Murdoch Children's Research Institute
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Vandenplas Y, Mukherjee R, Dupont C, Eigenmann P, Høst A, Kuitunen M, Ribes-Koninkx C, Shah N, Szajewska H, von Berg A, Heine RG, Zhao ZY. Protocol for the validation of sensitivity and specificity of the Cow's Milk-related Symptom Score (CoMiSS) against open food challenge in a single-blinded, prospective, multicentre trial in infants. BMJ Open 2018; 8:e019968. [PMID: 29773698 PMCID: PMC5961578 DOI: 10.1136/bmjopen-2017-019968] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/26/2018] [Accepted: 03/07/2018] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The symptoms of cow's milk protein allergy (CMPA) in infancy can be non-specific which may delay a correct diagnosis and cause adverse clinical outcomes. The diagnosis of non-IgE-mediated CMPA is particularly complex as it involves a 2 to 4 week elimination diet followed by oral food challenge (OFC). The Cow's Milk-related Symptom Score (CoMiSS) is a clinical resource for primary healthcare providers which aims to increase awareness of CMPA symptoms to facilitate an earlier diagnosis. The aim of the present study is to assess if the CoMiSS can be used as a potential diagnostic tool in infants with suspected CMPA. METHODS AND ANALYSIS Exclusively formula-fed infants aged 0-6 months presenting with symptoms suggestive of CMPA will be included in this prospective, multicentre trial which will be conducted in 10 centres in China. All infants will commence a 2-week trial of an amino acid-based formula (AAF) while eliminating all cow milk protein from their diets. After the AAF treatment period, infants will undergo an open OFC in hospital with standard cow's milk formula, followed by an open home challenge for another 2 weeks. Clinical symptoms will be documented on standardised symptom scorecards. The CoMiSS will be determined at study entry (CoMiSS 1, before the start of the AAF), after 2 weeks (CoMiSS 2, before the OFC) and after a further period of 2 weeks or when symptoms suggestive of CMPA reappear (CoMiSS 3). Weight and length will be measured at each visit. The difference between CoMiSS 1 and 2 as a predictor of the OFC outcome will also be assessed. The diagnostic accuracy of the baseline CoMiSS will be calculated. ETHICS AND DISSEMINATION The study was approved by the Hunan Children's Hospital Medical Ethics Committee, Hunan, China. The findings of this trial will be submitted for publication in a peer-reviewed journal in paediatric nutrition or gastroenterology. Abstracts will be submitted to the relevant national and international conferences. TRIAL REGISTRATION NUMBER NCT03004729; Pre-results.
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Affiliation(s)
- Yvan Vandenplas
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Christophe Dupont
- Hôpital Necker-Enfants Malades, Université de Paris Descartes, Paris, France
- Clinique Pédiatrique Saint Antoine, Hôpital Saint Vincent de Paul, Groupement des Hôpitaux de l’Institut Catholique de Lille, Lille, France
| | - Philippe Eigenmann
- Paediatric Allergy Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Arne Høst
- Department of Paediatrics, Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
| | - Mikael Kuitunen
- Children’s Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Carmen Ribes-Koninkx
- Paediatric Gastroenterology and Hepatology Unit, La Fe University Hospital, Valencia, Spain
| | - Neil Shah
- Great Ormond Street Hospital for Children, London, UK
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Andrea von Berg
- Department of Paediatrics, Research Institute, Marien-Hospital, Wezel, Germany
| | | | - Zheng-Yan Zhao
- Children’s Hospital Zhejiang, University School of Medicine, Hangzhou, China
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13
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Abstract
In view of the dramatic rise in the prevalence of food allergy globally, effective prevention strategies have become a public health priority. Several models have emerged around the etiology of food allergy, including the hygiene hypothesis, dual allergen exposure hypothesis, and vitamin D hypothesis. These form the basis for current and potential prevention strategies. Breastfeeding remains a key pillar of primary allergy prevention. Other nutritional interventions, including the use of whey-based, partially hydrolyzed formula in non-breastfed infants, also play an important role. In recent years, there has been a shift away from prolonged food allergen avoidance to the proactive allergen introduction from 4 months of age. This approach is supported by 2 pivotal randomized clinical trials showing that the early introduction of peanut and other food allergens significantly reduces the risk of food allergy. However, the implementation of this strategy at the population level still raises significant logistic problems, including patient selection and development of suitable food formats for young infants. Other prevention strategies, including vitamin D supplementation, are currently under evaluation. Maternal elimination diets during pregnancy and lactation are not recommended for allergy prevention. The treatment of food allergies has also seen major transformations. While strict allergen avoidance is still the key treatment principle, there is a greater focus on desensitization and tolerance induction by oral and epicutaneous immunotherapy. In addition, specialized hypoallergenic infant formulas for the treatment of infants with cow's milk allergy have undergone reformulation, including the addition of lactose and probiotics in order to modulate the gut microbiome and early immune responses. Further research is needed to inform the most effective food allergy prevention strategies at the population level. In addition, the wider application of food allergen immunotherapy may provide better health outcomes and improved quality of life for families affected by food allergies.
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Venter C, Brown T, Meyer R, Walsh J, Shah N, Nowak-Węgrzyn A, Chen TX, Fleischer DM, Heine RG, Levin M, Vieira MC, Fox AT. Correction to: Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy 2018; 8:4. [PMID: 29416848 PMCID: PMC5785850 DOI: 10.1186/s13601-017-0189-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Box B518, 13123 East 16th Avenue, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Trevor Brown
- 2Children's Allergy Service, Ulster Hospital, Belfast, BT16 1RH Northern Ireland, UK
| | - Rosan Meyer
- 3Department Paediatrics, Imperial College, London, London, W2 1NY UK
| | - Joanne Walsh
- Gurney Surgery, Castle Partnership, 101-103 Magdalen Street, Norwich, NR3 1LN UK
| | - Neil Shah
- 5Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH UK
| | - Anna Nowak-Węgrzyn
- 6Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Tong-Xin Chen
- 7Department of Allergy and Immunology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127 China
| | - David M Fleischer
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Box B518, 13123 East 16th Avenue, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Ralf G Heine
- 8Royal Children's Hospital Melbourne, Murdoch Children's Research Institute, Parkville, VIC 3052 Australia
| | - Michael Levin
- 9Division of Paediatric Allergy and Asthma, Red Cross War Memorial Children's Hospital, University of Cape Town, Room 516, ICH Building, Cape Town, South Africa
| | - Mario C Vieira
- 10Centro de Gastroenterologica Pediatrica, Department of Paediatrics, Hospital Pequeno Principe, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Adam T Fox
- 11Department of Paediatric Allergy, Guys and St Thomas' Hospitals NHS Foundation Trust, London, UK.,12Division of Asthma, Allergy and Lung Biology, King's College, London, London, UK
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15
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Heine RG, AlRefaee F, Bachina P, De Leon JC, Geng L, Gong S, Madrazo JA, Ngamphaiboon J, Ong C, Rogacion JM. Lactose intolerance and gastrointestinal cow's milk allergy in infants and children - common misconceptions revisited. World Allergy Organ J 2017; 10:41. [PMID: 29270244 PMCID: PMC5726035 DOI: 10.1186/s40413-017-0173-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/15/2017] [Indexed: 02/07/2023] Open
Abstract
Lactose is the main carbohydrate in human and mammalian milk. Lactose requires enzymatic hydrolysis by lactase into D-glucose and D-galactose before it can be absorbed. Term infants express sufficient lactase to digest about one liter of breast milk daily. Physiological lactose malabsorption in infancy confers beneficial prebiotic effects, including the establishment of Bifidobacterium-rich fecal microbiota. In many populations, lactase levels decline after weaning (lactase non-persistence; LNP). LNP affects about 70% of the world’s population and is the physiological basis for primary lactose intolerance (LI). Persistence of lactase beyond infancy is linked to several single nucleotide polymorphisms in the lactase gene promoter region on chromosome 2. Primary LI generally does not manifest clinically before 5 years of age. LI in young children is typically caused by underlying gut conditions, such as viral gastroenteritis, giardiasis, cow’s milk enteropathy, celiac disease or Crohn’s disease. Therefore, LI in childhood is mostly transient and improves with resolution of the underlying pathology. There is ongoing confusion between LI and cow’s milk allergy (CMA) which still leads to misdiagnosis and inappropriate dietary management. In addition, perceived LI may cause unnecessary milk restriction and adverse nutritional outcomes. The treatment of LI involves the reduction, but not complete elimination, of lactose-containing foods. By contrast, breastfed infants with suspected CMA should undergo a trial of a strict cow’s milk protein-free maternal elimination diet. If the infant is not breastfed, an extensively hydrolyzed or amino acid-based formula and strict cow’s milk avoidance are the standard treatment for CMA. The majority of infants with CMA can tolerate lactose, except when an enteropathy with secondary lactase deficiency is present.
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Affiliation(s)
- Ralf G Heine
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Fawaz AlRefaee
- Al Adan Hospital, Ministry of Health, Kuwait City, Kuwait
| | | | - Julie C De Leon
- Philippine Society of Allergy, Asthma & Immunology, Philippine Medical Association, Quezon City, Philippines
| | - Lanlan Geng
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Sitang Gong
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - José Armando Madrazo
- Universidad National Autonoma de México, Hospital Infantil Privado Star Médica, Polanco, Mexico City, Mexico
| | | | - Christina Ong
- KK Women's and Children's Hospital and Yong Loo Lin School of Medicine and Duke-NUS Medical School, Singapore, Singapore
| | - Jossie M Rogacion
- University of the Philippines, Philippine General Hospital, Manila, Philippines
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16
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Venter C, Brown T, Meyer R, Walsh J, Shah N, Nowak-Węgrzyn A, Chen TX, Fleischer DM, Heine RG, Levin M, Vieira MC, Fox AT. Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy 2017; 7:26. [PMID: 28852472 PMCID: PMC5567723 DOI: 10.1186/s13601-017-0162-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 06/30/2017] [Indexed: 12/18/2022] Open
Abstract
Cow’s milk allergy (CMA) is one of the most common presentations of food allergy seen in early childhood. It is also one of the most complex food allergies, being implicated in IgE-mediated food allergy as well as diverse manifestations of non-IgE-mediated food allergy. For example, gastrointestinal CMA may present as food protein induced enteropathy, enterocolitis or proctocolitis. Concerns regarding the early and timely diagnosis of CMA have been highlighted over the years. In response to these, guideline papers from the United Kingdom (UK), Australia, Europe, the Americas and the World Allergy Organisation have been published. The UK guideline, ‘Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy—a UK primary care practical guide’ was published in this journal in 2013. This Milk Allergy in Primary Care (MAP) guideline outlines in simple algorithmic form, both the varying presentations of cow’s milk allergy and also focuses on the practical management of the most common presentation, namely mild-to-moderate non-IgE-mediated allergy. Based on the international uptake of the MAP guideline, it became clear that there was a need for practical guidance beyond the UK. Consequently, this paper presents an international interpretation of the MAP guideline to help practitioners in primary care settings around the world. It incorporates further published UK guidance, feedback from UK healthcare professionals and affected families and, importantly, also international guidance and expertise.
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Affiliation(s)
- Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado , Box B518, 13123 East 16th Avenue, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Trevor Brown
- Children's Allergy Service, Ulster Hospital, Belfast, BT16 1RH Northern Ireland, UK
| | - Rosan Meyer
- Department Paediatrics, Imperial College, London, London, W2 1NY UK
| | - Joanne Walsh
- Gurney Surgery, Castle Partnership, 101-103 Magdalen Street, Norwich, NR3 1LN UK
| | - Neil Shah
- Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH UK
| | - Anna Nowak-Węgrzyn
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Tong-Xin Chen
- Department of Allergy and Immunology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127 China
| | - David M Fleischer
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado , Box B518, 13123 East 16th Avenue, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Ralf G Heine
- Royal Children's Hospital Melbourne, Murdoch Children's Research Institute, Parkville, VIC 3052 Australia
| | - Michael Levin
- Division of Paediatric Allergy and Asthma, Red Cross War Memorial Children's Hospital, University of Cape Town, Room 516, ICH Building, Cape Town, South Africa
| | - Mario C Vieira
- Centro de Gastroenterologica Pediatrica, Department of Paediatrics, Hospital Pequeno Principe, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Adam T Fox
- Department of Paediatric Allergy, Guys and St Thomas' Hospitals NHS Foundation Trust, London, UK.,Division of Asthma, Allergy and Lung Biology, King's College, London, London, UK
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17
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Loke P, Heine RG, McWilliam V, Cameron DJS, Tang MLK, Allen KJ. Fecal microbial transplantation in a pediatric case of recurrent Clostridium difficile infection and specific antibody deficiency. Pediatr Allergy Immunol 2016; 27:872-874. [PMID: 27496525 DOI: 10.1111/pai.12619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paxton Loke
- Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Vic., Australia
| | - Ralf G Heine
- Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Murdoch Childrens Research Institute, Parkville, Vic., Australia
| | - Vicki McWilliam
- Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Childrens Research Institute, Parkville, Vic., Australia
| | - Donald J S Cameron
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Murdoch Childrens Research Institute, Parkville, Vic., Australia
| | - Mimi L K Tang
- Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Murdoch Childrens Research Institute, Parkville, Vic., Australia
| | - Katrina J Allen
- Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Murdoch Childrens Research Institute, Parkville, Vic., Australia.,Institute of Inflammation and Repair, University of Manchester, Manchester, UK
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18
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Zurzolo GA, Koplin JJ, Ponsonby AL, McWilliam V, Dharmage S, Heine RG, Tang ML, Prescott S, Campbell DE, Loh R, Rueter K, Netting M, Frith K, Norton W, Said M, Gold M, Lee NA, Mathai M, de Courten M, Allen KJ. Consensus of stakeholders on precautionary allergen labelling: A report from the Centre for Food and Allergy Research. J Paediatr Child Health 2016; 52:797-801. [PMID: 27203701 DOI: 10.1111/jpc.13202] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Giovanni A Zurzolo
- Murdoch Children's Research Institute, Centre for Food and Allergy Research, Melbourne, Victoria, Australia.,Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, Melbourne, Victoria, Australia
| | - Jennifer J Koplin
- Murdoch Children's Research Institute, Centre for Food and Allergy Research, Melbourne, Victoria, Australia
| | - Anne-Louise Ponsonby
- Murdoch Children's Research Institute, Centre for Food and Allergy Research, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Vicki McWilliam
- Murdoch Children's Research Institute, Centre for Food and Allergy Research, Melbourne, Victoria, Australia
| | - Shyamali Dharmage
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Ralf G Heine
- Murdoch Children's Research Institute, Centre for Food and Allergy Research, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mimi Lk Tang
- Murdoch Children's Research Institute, Centre for Food and Allergy Research, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Prescott
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | | | - Richard Loh
- Princess Margaret Hospital for Children, Western Australia, Australia
| | - Kristina Rueter
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.,Princess Margaret Hospital for Children, Western Australia, Australia
| | - Merryn Netting
- Women's and Children's Health Research Institute, North Adelaide, Australia.,Discipline of Paediatrics, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Katie Frith
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Australia
| | | | - Maria Said
- Allergy & Anaphylaxis, Adelaide, Australia
| | - Michael Gold
- Department of Allergy, Women's and Children's Hospital, Adelaide, Australia
| | - N Alicec Lee
- ARC Training Centre for Advanced Technologies in Food Manufacture, The University of New South Wales, Sydney, Australia
| | - Michael Mathai
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, Melbourne, Victoria, Australia
| | - Maximilian de Courten
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, Melbourne, Victoria, Australia
| | - Katrina J Allen
- Centre for Chronic Disease, College of Health and Biomedicine, Victoria University, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia
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19
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Judd LM, Heine RG, Menheniott TR, Buzzelli J, O'Brien-Simpson N, Pavlic D, O'Connor L, Al Gazali K, Hamilton O, Scurr M, Collison AM, Mattes J, Allen KJ, Giraud AS. Elevated IL-33 expression is associated with pediatric eosinophilic esophagitis, and exogenous IL-33 promotes eosinophilic esophagitis development in mice. Am J Physiol Gastrointest Liver Physiol 2016; 310:G13-25. [PMID: 26514775 DOI: 10.1152/ajpgi.00290.2015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/08/2015] [Indexed: 01/31/2023]
Abstract
We tested whether the T helper (Th) type 2 (Th2) cell agonist and allergenic ligand IL-33 was associated with eosinophilic esophagitis (EoE) development in a pediatric cohort and whether IL-33 protein could induce disease symptoms in mice. Biopsies from EoE patients or controls were used to measure IL-33 mRNA and protein expression. Increased expression of IL-33 mRNA was found in the esophageal mucosa in EoE. IL-33 protein was detected in cells negative for CD45, mast cells, and epithelial cell markers near blood vessels. Circulating levels of IL-33 were not increased. The time course for IL-33 gene expression was quantified in an established Aspergillus fumigatus allergen mouse model of EoE. Because IL-33 induction was transient in this model and chronicity of IL-33 expression has been demonstrated in humans, naive mice were treated with recombinant IL-33 for 1 wk and esophageal pathology was evaluated. IL-33 application produced changes consistent with phenotypically early EoE, including transmural eosinophilia, mucosal hyperproliferation, and upregulation of eosinophilic genes and chemokines. Th2 cytokines, including IL-13, along with innate lymphoid cell group 2, Th1/17, and M2 macrophage marker genes, were increased after IL-33 application. IL-33-induced eosinophilia was ablated in IL-13 null mice. In addition, IL-33 induced a profound inhibition of the regulatory T cell gene signature. We conclude that IL-33 gene expression is associated with pediatric EoE development and that application of recombinant protein in mice phenocopies the early clinical phase of the human disease in an IL-13-dependent manner. IL-33 inhibition of esophageal regulatory T cell function may induce loss of antigenic tolerance, thereby providing a mechanistic rationale for EoE development.
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Affiliation(s)
- L M Judd
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - R G Heine
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Parkville, Victoria, Australia; Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - T R Menheniott
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - J Buzzelli
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - N O'Brien-Simpson
- Oral Health Cooperative Research Center, Melbourne Dental School, University of Melbourne, Parkville, Victoria, Australia; and
| | - D Pavlic
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - L O'Connor
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - K Al Gazali
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - O Hamilton
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - M Scurr
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - A M Collison
- Priority Research Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - J Mattes
- Priority Research Centre for Asthma and Respiratory Diseases, University of Newcastle and Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - K J Allen
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Parkville, Victoria, Australia; Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - A S Giraud
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia;
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20
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Heine RG. Insights into the emerging epidemic of eosinophilic oesophagitis. Best Pract Res Clin Gastroenterol 2015; 29:731-737. [PMID: 26552772 DOI: 10.1016/j.bpg.2015.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 08/24/2015] [Accepted: 09/02/2015] [Indexed: 02/07/2023]
Abstract
Eosinophilic oesophagitis (EOE) is a relatively recently recognised condition characterised by an increase in oesophageal eosinophils. EOE occurs in children and adults with a strong male preponderance. There has been a sharp increase in EOE in North America, Europe and Australia. The reasons for this increase remain unclear but are likely to be influenced by genetic and environmental factors, as well as early-life exposures. Based on recent population-based data, the estimated EOE prevalence in the USA is 56.7 per 100,000 persons. The peak prevalence was observed in patients between 35 and 39 years of age. Prevalence figures in Asia and the Middle East generally appear to be lower than in Western countries, but population-based studies are not available. A causal association between coeliac disease and EOE appears unlikely. Data on the seasonal variation of EOE remain inconclusive. Further population-based studies are needed to define the epidemiology of EOE.
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Affiliation(s)
- Ralf G Heine
- Dept. of Gastroenterology & Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia; Dept. of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia.
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21
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Ledder O, Oliver MR, Heine RG, Graham J, Volders E, Robinson PJ. Clinical audit results in earlier nutritional intervention in malnourished children with cystic fibrosis with improved outcome. J Paediatr Child Health 2015; 51:988-93. [PMID: 25873203 DOI: 10.1111/jpc.12888] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 11/30/2022]
Abstract
AIM The association between nutritional status, pulmonary function and survival in cystic fibrosis (CF) is well established. A previous case series from the Royal Children's Hospital, Melbourne (RCH), demonstrated suboptimal referral practices and highlighted the importance of early nutritional interventions in children with CF. Various qualitative changes were made to our CF service, and this study assesses the effects of these practice changes timing of gastrostomy and clinical outcome in patients who underwent gastrostomy insertion. METHOD Clinical audit of all CF patients who had undergone gastrostomy insertion from 2002 to 2010 at Royal Children's Hospital. Clinical data, including nutritional parameters, respiratory function and survival, were collected at 2 years prior and 2 years post gastrostomy insertion. Data were compared with the previous study from 1989 to 1997. RESULTS Patients with CF who underwent gastrostomy insertion between 2002 and 2010 (n = 22) had higher weight-for-age scores (-1.5 ± 0.68 vs. -2.67 ± 1.06; P = 0.0001) and higher forced expiratory volume in 1 s (68% ± 22 vs. 52% ± 18.5; P = 0.006), compared with the cohort from 1989 to 1997 (n = 37). These differences were maintained at 2-year follow-up. Pseudomonas aeruginosa colonisation rate was 100% in 1989-1997 vs. 41% in 2002-2010; P = 0.0001. The 2-year survival post-gastrostomy insertion improved from 70% to 100%; P = 0.004. CONCLUSION Earlier referral of patients in the recent cohort resulted in sustained improvements in weight-for-age and lung function. Survival at 2 years post-procedure was significantly improved. This study confirms the value of clinical audits and subsequent re-evaluation of clinical services.
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Affiliation(s)
- Oren Ledder
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mark R Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Joanne Graham
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Evelyn Volders
- Department of Nutrition & Dietetics, Monash University, Melbourne, Victoria, Australia
| | - Philip J Robinson
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
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Abstract
Eosinophilic oesophagitis (EoE) is an antigen-driven pan-oesophagitis that is defined by the presence of at least 15 eosinophils per high power field on oesophageal histology in conjunction with upper gastrointestinal symptoms. EoE is closely associated with atopic disorders, in particular with food allergy, and as for other atopic diseases in childhood, there is a strong preponderance of male patients who have this disorder. The mechanisms leading to EoE have been characterised at the molecular level. Eotaxin-3, interleukin-5 and interleukin-13 are the key effector molecules in EoE pathogenesis. EoE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or feeding refusal in infancy, as well as heartburn, dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained as an incidental finding in patients undergoing gastroscopy for other suspected conditions, including coeliac disease. EoE is different from gastro-oesophageal reflux disease and does not improve in response to proton pump inhibitors. Therefore, EoE needs to be distinguished from so-called PPI-responsive oesophageal eosinophilia. The long-term prognosis of EoE remains poorly defined, and complications mainly relate to subepithelial remodelling and fibrosis that may result in dysmotility, dysphagia and oesophageal strictures. The treatment of EoE involves elimination diets and topical swallowed aerosolised corticosteroids, while biological therapies targeting molecular mechanisms have so far been unsuccessful. In children, elemental diets have proved highly effective, but multiple food elimination diets are more sustainable in the long term. Further randomised, controlled trials on dietary or pharmacological interventions are needed to inform the optimal long-term management of EoE.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition and Department of Allergy and Immunology, The Royal Children's Hospital Melbourne, Melbourne, Vic., Australia
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23
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Abstract
Gastrointestinal food allergies present during early childhood with a diverse range of symptoms. Cow's milk, soy and wheat are the three most common gastrointestinal food allergens. Several clinical syndromes have been described, including food protein-induced enteropathy, proctocolitis and enterocolitis. In contrast with immediate, IgE-mediated food allergies, the onset of gastrointestinal symptoms is delayed for at least 1-2 hours after ingestion in non-IgE-mediated allergic disorders. The pathophysiology of these non-IgE-mediated allergic disorders is poorly understood, and useful in vitro markers are lacking. The results of the skin prick test or measurement of the food-specific serum IgE level is generally negative, although low-positive results may occur. Diagnosis therefore relies on the recognition of a particular clinical phenotype as well as the demonstration of clear clinical improvement after food allergen elimination and the re-emergence of symptoms upon challenge. There is a significant clinical overlap between non-IgE-mediated food allergy and several common paediatric gastroenterological conditions, which may lead to diagnostic confusion. The treatment of gastrointestinal food allergies requires the strict elimination of offending food allergens until tolerance has developed. In breast-fed infants, a maternal elimination diet is often sufficient to control symptoms. In formula-fed infants, treatment usually involves the use an extensively hydrolysed or amino acid-based formula. Apart from the use of hypoallergenic formulae, the solid diets of these children also need to be kept free of specific food allergens, as clinically indicated. The nutritional progress of infants and young children should be carefully monitored, and they should undergo ongoing, regular food protein elimination reassessments by cautious food challenges to monitor for possible tolerance development.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition and Department of Allergy and Immunology, The Royal Children's Hospital Melbourne, Melbourne, Vic., Murdoch Childrens Research Institute, Melbourne, Vic., and Department of Paediatrics, The University of Melbourne, Melbourne, Vic., Australia
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24
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Abstract
Eosinophilic oesophagitis (EoE) is a key differential for gastro-oesophageal reflux (GOR) in children. It can be difficult for clinicians to decide which patients need referral for the assessment of EoE, which can only be confirmed by histological analysis of endoscopic biopsies. Recent guidelines recommend that EoE can only be diagnosed following the exclusion of GOR through empiric treatment with proton pump inhibitors prior to endoscopy. Some aspects of history are strongly suggestive of EoE: red flags for referral include poor weight gain in the context of reflux symptoms, choking during eating or food impaction. Therapeutic options include dietary allergen elimination or swallowed aerosolised corticosteroids. Other novel therapies have failed to demonstrate benefit, but novel diagnostic biomarkers to enable non-invasive disease ascertainment and follow-up show some promise.
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Affiliation(s)
- Katrina J Allen
- Department of Allergy, Gastroenterology and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Centre of Food and Allergy Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Ralf G Heine
- Department of Allergy, Gastroenterology and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Centre of Food and Allergy Research, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
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Hua S, Peters RL, Allen KJ, Dharmage SC, Tang ML, Wake M, Foskey R, Heine RG. Medical intervention in parent-reported infant gastro-oesophageal reflux: A population-based study. J Paediatr Child Health 2015; 51:515-523. [PMID: 25393964 DOI: 10.1111/jpc.12760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 11/29/2022]
Abstract
AIM To report the cumulative incidence, health-seeking behaviour and medical intervention of infants with gastro-oesophageal reflux (GOR) in the first year of life. METHODS The HealthNuts study is a longitudinal, population-based study. At 12 months of age, infants underwent skin prick testing to food allergens, including cows milk. Parents completed a questionnaire on GOR symptoms, food allergy and treatments. Factors associated with seeking health care for infants with GOR were modelled using logistic regression. RESULTS Of 4674 infants, parents reported GOR in 1054 (23%; 95% confidence interval (CI) 21.4-23.8). Parents consulted a medical practitioner in 662 (64%) cases. Symptoms commenced in the first month in 411 (48%) and resolved within 6 months in 703 (75%) infants. Factors associated with doctor consultation for GOR were prematurity (adjusted odds ratio (aOR) 1.94; 95% CI 1.43-2.63) and family history of atopy (aOR 1.64; 95% CI 1.1-2.43). Eight per cent of infants (371/4674; 95% CI 7.2-8.7) received anti-reflux medication and 6% (296/4674; 95% CI 5.7-7.1) changed formula. Parents were more likely to seek treatment if they perceived their infant to be unsettled (aOR 2.55; 95% CI 1.26-5.17) and if the duration of GOR was prolonged (aOR 3.36 for symptoms >6 months; 95% CI 1.83-6.17). CONCLUSIONS In the first year of life, approximately 14% of the population seek medical advice for GOR symptoms. The use of anti-reflux medication in the general community remains high, despite the absence of evidence that it is appropriate or effective for uncomplicated GOR.
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Affiliation(s)
- Sun Hua
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Rachel L Peters
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Katrina J Allen
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Shyamali C Dharmage
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,School of Population Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mimi Lk Tang
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melissa Wake
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rebecca Foskey
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Monash School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ralf G Heine
- Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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McWilliam VL, Tang ML, Heine RG, Allen KJ. Multiple Food Protein Intolerance of Infancy or Severe Spectrum of Non-IgE-Mediated Cow's Milk Allergy? - a Case Series. J Allergy Clin Immunol 2015. [DOI: 10.1016/j.jaci.2014.12.1891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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28
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Vandenplas Y, Cruchet S, Faure C, Lee HC, Di Lorenzo C, Staiano A, Chundi X, Aw MM, Gutiérrez-Castrellón P, Asery A, Spolidoro J, Heine RG, Miqdady M, Arancibia ME, Alarcón P. When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention? Acta Paediatr 2014; 103:689-95. [PMID: 24654945 DOI: 10.1111/apa.12637] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/17/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Experts reviewed the literature to determine whether partially whey hydrolysed formulas (HF) offer benefits in the dietary management of frequent gastrointestinal symptoms and allergy prevention. Compared with standard cow's milk-based formulas, partially whey HF confer a limited protective effect against allergic disease in high-risk infants, particularly atopic dermatitis, but not respiratory allergies. No randomised clinical trials have been published on partially whey HF in infants with colicky symptoms. The group did not find sufficient evidence to support the use of partially whey HF in regurgitation, although recent data suggest that a thickened partially whey HF may be more effective. Partially whey HF, fortified with prebiotics and/or probiotics, with high levels of sn-2 palmitate in the fat blend or without palm oil, provide some benefit in functional constipation. CONCLUSION Overall, partially whey HF may offer a useful alternative to intact protein in the dietary management of common functional gastrointestinal symptoms.
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Affiliation(s)
- Y Vandenplas
- UZ Brussel; Vrije Universiteit Brussel; Brussels Belgium
| | - S Cruchet
- INTA; Universidad de Chile; Santiago Chile
| | - C Faure
- Department of Pediatrics; Université de Montréal; Montréal QC Canada
| | - HC Lee
- Department of Pediatrics; Mackay Memorial Hospital; Hsinchu and Taipei Medical University; Taipei Taiwan
| | - C Di Lorenzo
- Department of Pediatrics; Nationwide Children's Hospital; Columbus OH USA
| | - A Staiano
- Department of Pediatrics; University of Naples “Federico II”; Naples Italy
| | - Xu Chundi
- Ruijin Hospital; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - MM Aw
- Department of Paediatrics; Khoo Teck Puat-National University Children's Medical Institute; National University Hospital; Singapore City Singapore
- Department of Paediatrics; National University of Singapore; Singapore Singapore
| | - P Gutiérrez-Castrellón
- Facultad de Medicina; Instituto Nacional de Perinatologia; Hospital General “Dr. Manuel Gea Gonzalez”; Universidad La Salle; Mexico City Mexico
| | - A Asery
- Department of Pediatrics; King Fahad Medical City; Riyadh Saudi Arabia
| | - J Spolidoro
- Pontifícia Universidade Católica do Rio Grande do Sul, (PUCRS); Porto Alegre RS Brazil
| | - RG Heine
- Department of Allergy and Immunology; Royal Children's Hospital; Murdoch Children's Research Institute; University of Melbourne; Melbourne Vic. Australia
| | - M Miqdady
- Pediatric GI, Hepatology and Nutrition; Sheikh Khalifa Medical City; Abu Dhabi United Arab Emirates
| | | | - P Alarcón
- National Institute of Child Health; Lima Perú
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Sung V, Hiscock H, Tang MLK, Mensah FK, Nation ML, Satzke C, Heine RG, Stock A, Barr RG, Wake M. Treating infant colic with the probiotic Lactobacillus reuteri: double blind, placebo controlled randomised trial. BMJ 2014; 348:g2107. [PMID: 24690625 PMCID: PMC3972414 DOI: 10.1136/bmj.g2107] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine whether the probiotic Lactobacillus reuteri DSM 17938 reduces crying or fussing in a broad community based sample of breastfed infants and formula fed infants with colic aged less than 3 months. DESIGN Double blind, placebo controlled randomised trial. SETTING Community based sample (primary and secondary level care centres) in Melbourne, Australia. PARTICIPANTS 167 breastfed infants or formula fed infants aged less than 3 months meeting Wessel's criteria for crying or fussing: 85 were randomised to receive probiotic and 82 to receive placebo. INTERVENTIONS Oral daily L reuteri (1 × 10(8) colony forming units) versus placebo for one month. MAIN OUTCOMES MEASURES The primary outcome was daily duration of cry or fuss at 1 month. Secondary outcomes were duration of cry or fuss; number of cry or fuss episodes; sleep duration of infant at 7, 14, and 21 days, and 1 and 6 months; maternal mental health (Edinburgh postnatal depression subscale); family functioning (paediatric quality of life inventory), parent quality adjusted life years (assessment of quality of life) at 1 and 6 months; infant functioning (paediatric quality of life inventory) at 6 months; infant faecal microbiota (microbial diversity, colonisation with Escherichia coli), and calprotectin levels at 1 month. In intention to treat analyses the two groups were compared using regression models adjusted for potential confounders. RESULTS Of 167 infants randomised from August 2011 to August 2012, 127 (76%) were retained to primary outcome; of these, a subset was analysed for faecal microbial diversity, E coli colonisation, and calprotectin levels. Adherence was high. Mean daily cry or fuss time fell steadily in both groups. At 1 month, the probiotic group cried or fussed 49 minutes more than the placebo group (95% confidence interval 8 to 90 minutes, P=0.02); this mainly reflected more fussing, especially for formula fed infants. The groups were similar on all secondary outcomes. No study related adverse events occurred. CONCLUSIONS L reuteri DSM 17938 did not benefit a community sample of breastfed infants and formula fed infants with colic. These findings differ from previous smaller trials of selected populations and do not support a general recommendation for the use of probiotics to treat colic in infants. TRIAL REGISTRATION Current Controlled Trials ISRCTN95287767.
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Affiliation(s)
- Valerie Sung
- Royal Children's Hospital, Parkville, Victoria, Australia
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30
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Abstract
Due to the recent exponential increase in food allergies and atopic disorders, effective allergy prevention has become a public health priority in many developed regions. Important preventive strategies include the promotion of breastfeeding and vaginal deliveries, judicious use of perinatal antibiotics, as well as the avoidance of maternal tobacco smoking. Breastfeeding for at least 6 months and introduction of complementary solids from 4-6 months are generally recommended. Complex oligosaccharides in breast milk support the establishment of bifidobacteria in the neonatal gut which stimulate regulatory T lymphocyte responses and enhance tolerance development. Maternal elimination diets during pregnancy or lactation are not effective in preventing allergies. If exclusive breastfeeding is not possible, (supplemental) feeding with a partially hydrolyzed whey-based formula or extensively hydrolyzed casein-based formula may reduce the risk of cow's milk allergy and atopic dermatitis in infants with a family history of atopy. By contrast, asthma and allergic rhinitis at 4-6 years of age are not prevented by this approach. Soy formula and amino acid-based formula have no proven role in allergy prevention. Perinatal supplementation with probiotics and/or prebiotics may reduce the risk of atopic dermatitis, but no reliable effect on the prevention of food allergy or respiratory allergies has so far been found. A randomized trial on maternal fish oil supplementation during pregnancy found that atopic dermatitis and egg sensitization in the first year of life were significantly reduced, but no preventive effect for food allergies was demonstrated. The role of vitamin D deficiency or excess as a risk factor for food allergy and atopic disorders requires further study.
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Affiliation(s)
- Ralf G Heine
- Department of Allergy and Immunology, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
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31
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Lee AL, Button BM, Denehy L, Roberts SJ, Bamford TL, Ellis SJ, Mu FT, Heine RG, Stirling RG, Wilson JW. Proximal and distal gastro-oesophageal reflux in chronic obstructive pulmonary disease and bronchiectasis. Respirology 2013; 19:211-217. [DOI: 10.1111/resp.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/05/2013] [Accepted: 08/06/2013] [Indexed: 12/13/2022]
Affiliation(s)
- Annemarie L. Lee
- Physiotherapy, Melbourne School of Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Department of Physiotherapy; The Alfred; Melbourne Victoria Australia
| | - Brenda M. Button
- Department of Physiotherapy; The Alfred; Melbourne Victoria Australia
- Department of Medicine; Monash University; Melbourne Victoria Australia
- Department of Allergy, Immunology and Respiratory Medicine; The Alfred Hospital; Melbourne Victoria Australia
| | - Linda Denehy
- Physiotherapy, Melbourne School of Health Sciences; University of Melbourne; Melbourne Victoria Australia
| | - Stuart J. Roberts
- Department of Gastroenterology; The Alfred; Melbourne Victoria Australia
- Department of Medicine; Monash University; Melbourne Victoria Australia
| | - Tiffany L. Bamford
- Department of Medicine; Monash University; Melbourne Victoria Australia
- Janssen; Pharmaceutical Companies of Johnson and Johnson; Melbourne Victoria Australia
| | | | - Fi-Tjen Mu
- Department of Immunology; Monash University; Melbourne Victoria Australia
| | - Ralf G. Heine
- Murdoch Children's Research Institute; University of Melbourne; Melbourne Victoria Australia
- Department of Gastroenterology and Clinical Nutrition; Royal Children's Hospital; Melbourne Victoria Australia
| | - Robert G. Stirling
- Department of Medicine; Monash University; Melbourne Victoria Australia
- Department of Allergy, Immunology and Respiratory Medicine; The Alfred Hospital; Melbourne Victoria Australia
| | - John W. Wilson
- Department of Medicine; Monash University; Melbourne Victoria Australia
- Department of Allergy, Immunology and Respiratory Medicine; The Alfred Hospital; Melbourne Victoria Australia
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Fiocchi A, Burks W, Bahna SL, Bielory L, Boyle RJ, Cocco R, Dreborg S, Goodman R, Kuitunen M, Haahtela T, Heine RG, Lack G, Osborn DA, Sampson H, Tannock GW, Lee BW. Clinical Use of Probiotics in Pediatric Allergy (CUPPA): A World Allergy Organization Position Paper. World Allergy Organ J 2012; 5:148-67. [PMID: 23282383 PMCID: PMC3651185 DOI: 10.1097/wox.0b013e3182784ee0] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND : Probiotic administration has been proposed for the prevention and treatment of specific allergic manifestations such as eczema, rhinitis, gastrointestinal allergy, food allergy, and asthma. However, published statements and scientific opinions disagree about the clinical usefulness. OBJECTIVE : A World Allergy Organization Special Committee on Food Allergy and Nutrition review of the evidence regarding the use of probiotics for the prevention and treatment of allergy. METHODS : A qualitative and narrative review of the literature on probiotic treatment of allergic disease was carried out to address the diversity and variable quality of relevant studies. This variability precluded systematization, and an expert panel group discussion method was used to evaluate the literature. In the absence of systematic reviews of treatment, meta-analyses of prevention studies were used to provide data in support of probiotic applications. RESULTS : Despite the plethora of literature, probiotic research is still in its infancy. There is a need for basic microbiology research on the resident human microbiota. Mechanistic studies from biology, immunology, and genetics are needed before we can claim to harness the potential of immune modulatory effects of microbiota. Meanwhile, clinicians must take a step back and try to link disease state with alterations of the microbiota through well-controlled long-term studies to identify clinical indications. CONCLUSIONS : Probiotics do not have an established role in the prevention or treatment of allergy. No single probiotic supplement or class of supplements has been demonstrated to efficiently influence the course of any allergic manifestation or long-term disease or to be sufficient to do so. Further epidemiologic, immunologic, microbiologic, genetic, and clinical studies are necessary to determine whether probiotic supplements will be useful in preventing allergy. Until then, supplementation with probiotics remains empirical in allergy medicine. In the future, basic research should focus on homoeostatic studies, and clinical research should focus on preventive medicine applications, not only in allergy. Collaborations between allergo-immunologists and microbiologists in basic research and a multidisciplinary approach in clinical research are likely to be the most fruitful.
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Affiliation(s)
- Alessandro Fiocchi
- Department of Pediatrics - Division of Allergy - Pediatric Hospital Bambino Gesù - Rome, Vatican City
| | - Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Sami L Bahna
- Department of Pediatrics and Medicine, Section of Allergy and Immunology, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Leonard Bielory
- Department of Medicine, University of Medicine and Dentistry of New Jersey Medical School, Newark, NJ
| | - Robert J Boyle
- Department of Paediatrics, Imperial College London, London, UK
| | - Renata Cocco
- Division of Allergy, Clinical Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | - Sten Dreborg
- Department of Pediatric Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Richard Goodman
- Department of Food Science & Technology University of Nebraska, Lincoln, NE, USA
| | - Mikael Kuitunen
- Skin and Allergy Hospital, University of Helsinki, Helsinki, Finland
| | - Tari Haahtela
- Skin and Allergy Hospital, University of Helsinki, Helsinki, Finland
| | - Ralf G Heine
- Department of Allergy and Immunology, Royal Children's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Gideon Lack
- King's College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Paediatric Allergy, St Thomas' Hospital, London, UK
| | - David A Osborn
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Hugh Sampson
- Jaffe Food Allergy Institute, Mount Sinai School of Medicine, New York, NY
| | - Gerald W Tannock
- Department of Microbiology and Immunology, University of Otago, Dunedin, New Zealand
| | - Bee Wah Lee
- Department of Paediatrics, National University of Singapore, Singapore
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Sung V, Hiscock H, Tang M, Mensah FK, Heine RG, Stock A, York E, Barr RG, Wake M. Probiotics to improve outcomes of colic in the community: protocol for the Baby Biotics randomised controlled trial. BMC Pediatr 2012; 12:135. [PMID: 22928654 PMCID: PMC3508922 DOI: 10.1186/1471-2431-12-135] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/24/2012] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Infant colic, characterised by excessive crying/fussing for no apparent cause, affects up to 20% of infants under three months of age and is a great burden to families, health professionals and the health system. One promising approach to improving its management is the use of oral probiotics. The Baby Biotics trial aims to determine whether the probiotic Lactobacillus reuteri DSM 17938 is effective in reducing crying in infants less than three months old (<13.0 weeks) with infant colic when compared to placebo. METHODS/DESIGN DESIGN Double-blind, placebo-controlled randomised trial in Melbourne, Australia. PARTICIPANTS 160 breast and formula fed infants less than three months old who present either to clinical or community services and meet Wessel's criteria of crying and/or fussing. INTERVENTION Oral once-daily Lactobacillus reuteri (1x108 cfu) versus placebo for one month. PRIMARY OUTCOME Infant crying/fussing time per 24 hours at one month. SECONDARY OUTCOMES i) number of episodes of infant crying/fussing per 24 hours and ii) infant sleep duration per 24 hours (at 7, 14, 21, 28 days and 6 months); iii) maternal mental health scores, iv) family functioning scores, v) parent quality adjusted life years scores, and vi) intervention cost-effectiveness (at one and six months); and vii) infant faecal microbiota diversity, viii) infant faecal calprotectin levels and ix) Eschericia coli load (at one month only). ANALYSIS Primary and secondary outcomes for the intervention versus control groups will be compared with t tests and non-parametric tests for continuous data and chi squared tests for dichotomous data. Regression models will be used to adjust for potential confounding factors. Intention-to-treat analysis will be applied. DISCUSSION An effective, practical and acceptable intervention for infant colic would represent a major clinical advance. Because our trial includes breast and formula-fed babies, our results should generalise to most babies with colic. If cost-effective, the intervention's simplicity is such that it could be widely taken up as a new standard of care in the primary and secondary care sectors. TRIAL REGISTRATION Current Controlled Trials ISRCTN95287767.
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Affiliation(s)
- Valerie Sung
- Royal Children's Hospital, Parkville, Australia.
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Lee AL, Denehy L, Wilson JW, Roberts S, Stirling RG, Heine RG, Button BM. Upright positive expiratory pressure therapy and exercise: effects on gastroesophageal reflux in COPD and bronchiectasis. Respir Care 2012; 57:1460-7. [PMID: 22348601 DOI: 10.4187/respcare.01498] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with COPD and patients with bronchiectasis undertake airway clearance therapy and exercise as part of management, but the effect of these activities on gastroesophageal acid exposure is unknown. This study aimed to determine if positive expiratory pressure (PEP) therapy and standardized exercise tasks were associated with increased gastroesophageal reflux. METHODS During dual-probe 24 hour esophageal pH monitoring, all participants undertook a single session of PEP therapy, a measure of submaximal exercise capacity (6-min walk test [6MWT]), and a functional upper limb task (grocery shelving task [GST]). The number of reflux episodes and fractional reflux time (reflux index [RI]) were recorded during each intervention and compared to equivalent background time (BGT). RESULTS Fifty-seven participants (30 with bronchiectasis, 27 with COPD, mean ± SD age 61 ± 13 y, FEV(1) 61.2 ± 24.6% predicted) completed the study. Episodes of isolated distal esophageal reflux occurred in 30% of participants during PEP therapy, 22% during the 6MWT, and 20% during the GST. However, there was no significant difference in distal RI during 6MWT or PEP therapy, compared to BGT (all P > .05). The number of reflux episodes was decreased, compared to BGT during the GST (P = .001) and 6MWT (P = .001), but not during PEP therapy (P = .71). CONCLUSIONS Episodes of gastroesophageal reflux may occur during physiotherapy tasks, including airway clearance therapy using mouthpiece PEP, the 6MWT, and a measure of upper limb movement. However, as these activities did not increase the frequency of these events, no modifications to these tasks to minimize the occurrence of gastroesophageal reflux are necessary.
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Affiliation(s)
- Annemarie L Lee
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia. annlee@unimelbeduau
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Su J, Prescott S, Sinn J, Tang M, Smith P, Heine RG, Spieldenner J, Iskedjian M. Cost-effectiveness of partially-hydrolyzed formula for prevention of atopic dermatitis in Australia. J Med Econ 2012; 15:1064-77. [PMID: 22630113 DOI: 10.3111/13696998.2012.697085] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To perform an economic evaluation of a specific brand of partially hydrolyzed infant formula (PHF-W) in the prevention of atopic dermatitis (AD) among Australian infants. METHODS A cost-effectiveness analysis was undertaken from the perspectives of the Department of Health and Aging (DHA), of the family of the affected subject and of society as a whole in Australia, based on a decision-analytic model following a hypothetical representative cohort of Australian newborns who are not exclusively breastfed and who have a familial history of allergic disease (i.e., are deemed 'at risk'). Costs, consequences, and incremental cost-effectiveness ratios (ICER) were calculated for PHF-W vs standard cow's milk based infant formula (SF), and, in a secondary analysis, vs extensively hydrolyzed infant formula (EHF-Whey), when the latter was used for the prevention of AD. RESULTS From a representative starting cohort of 87,724 'at risk' newborns in Australia in 2009, the expected ICERs for PHF-W vs SF were AU$496 from the perspective of the DHA and savings of AUD1739 and AU$1243 from the family and societal perspectives, respectively. When compared to EHF-Whey, PHF-W was associated with savings for the cohort of AU$5,183,474 and AU$6,736,513 from the DHA and societal perspectives. LIMITATIONS The generalizability and transferability of results to other settings, populations, or brands of infant formula should be made with caution. Whenever possible, a conservative approach directing bias against PHF-W rather than its comparators was applied in the base case analysis. Assumptions were verified in one-way and probabilistic sensitivity analyses, which confirmed the robustness of the model. CONCLUSIONS PHF-W appears to be cost-effective when compared to SF from the DHA perspective, dominant over SF from the other perspectives, and dominant over EHF-Whey from all perspectives, in the prevention of AD in 'at risk' infants not exclusively breastfed, in Australia.
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Affiliation(s)
- John Su
- Department of Dermatology, Royal Children's Hospital, University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia
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Abstract
OBJECTIVE To compare the efficacy of 2 nasogastric rehydration regimens for children with acute viral gastroenteritis. METHODS Children 6 to 72 months of age with acute viral gastroenteritis and moderate dehydration were recruited from emergency departments (EDs) at 2 metropolitan, pediatric, teaching hospitals. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either standard nasogastric rehydration (SNR) over 24 hours in the hospital ward or rapid nasogastric rehydration (RNR) over 4 hours in the ED. Primary (>2% weight loss, compared with the admission weight) and secondary treatment failures were assessed. RESULTS Of 9331 children with acute gastroenteritis who were screened, 254 children were assigned randomly to receive either RNR (n = 132 [52.0%]) or SNR (n = 122 [48.0%]). Baseline characteristics for the 2 groups were similar. All patients made a full recovery without severe adverse events. The primary failure rates were similar for RNR (11.8% [95% confidence interval [CI]: 6.0%-17.6%]) and SNR (9.2% [95% CI: 3.7%-14.7%]; P = .52). Secondary treatment failure was more common in the SNR group (44% [95% CI: 34.6%-53.4%]) than in the RNR group (30.3% [95% CI: 22.5%-38.8%]; P = .03). Discharge from the ED after RNR failed for 27 patients (22.7%), and another 9 (7.6%) were readmitted to the hospital within 24 hours. CONCLUSIONS Primary treatment failure and clinical outcomes were similar for RNR and SNR. Although RNR generally reduced the need for hospitalization, discharge home from the ED failed for approximately one-fourth of the patients.
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Affiliation(s)
- Colin V E Powell
- Departments of aEmergency Medicine, Royal Children’s Hospital, Melbourne, Australia
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Abstract
Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition and Royal Children's Hospital, Melbourne, Australia
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Fiocchi A, Schünemann HJ, Brozek J, Restani P, Beyer K, Troncone R, Martelli A, Terracciano L, Bahna SL, Rancé F, Ebisawa M, Heine RG, Assa'ad A, Sampson H, Verduci E, Bouygue GR, Baena-Cagnani C, Canonica W, Lockey RF. Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA): a summary report. J Allergy Clin Immunol 2011; 126:1119-28.e12. [PMID: 21134569 DOI: 10.1016/j.jaci.2010.10.011] [Citation(s) in RCA: 174] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 09/30/2010] [Accepted: 10/01/2010] [Indexed: 01/28/2023]
Abstract
The 2nd Milan Meeting on Adverse Reactions to Bovine Proteins was the venue for the presentation of the first consensus-based approach to the management of cow's milk allergy. It was also the first time that the Grading of Recommendations, Assessments, Development, and Evaluation approach for formulating guidelines and recommendations was applied to the field of food allergy. In this report we present the contributions in allergen science, epidemiology, natural history, evidence-based diagnosis, and therapy synthesized in the World Allergy Organization Diagnosis and Rationale for Action against Cow's Milk Allergy guidelines and presented during the meeting. A consensus emerged between discussants that cow's milk allergy management should reflect not only basic research but also a newer and better appraisal of the literature in the light of the values and preferences shared by patients and their caregivers in partnership. In the field of diagnosis, atopy patch testing and microarray technology have not yet evolved for use outside the research setting. With foreseeable breakthroughs (eg, immunotherapy and molecular diagnosis) in the offing, the step ahead in leadership can only stem from a worldwide organization implementing consensus-based clinical practice guidelines to diffuse and share clinical knowledge.
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Affiliation(s)
- Alessandro Fiocchi
- Department of Child and Maternal Medicine, Melloni Hospital, Milan, Italy.
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Abstract
Cow's milk protein (CMP) is usually one of the first complementary foods to be introduced into the infant's diet and is commonly consumed throughout childhood as part of a balanced diet. CMP is capable of inducing a multitude of adverse reactions in children, which may involve organs like the skin, gastrointestinal (GI) tract or respiratory system. The diagnosis of CMP-induced adverse reactions requires an understanding of their classification and immunological basis as well as the strengths and limitations of diagnostic modalities. In addition to the well-recognised, immediate-onset IgE-mediated allergies, there is increasing evidence to support the role of CMP-induced allergy in a spectrum of delayed-onset disorders ranging from GI symptoms to chronic eczema. The mainstay of treatment is avoidance of CMP; this requires dietetic input to ensure that this does not lead to any nutritional compromise. This review is intended to highlight the broad spectrum of manifestations of CMP allergy and to offer an approach to the diagnosis and treatment thereof.
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Affiliation(s)
- George du Toit
- King’s College London, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Allergy and Lung Biology, Guy’s and St Thomas’ NHS Foundation Trust, UK.
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Fiocchi A, Brozek J, Schünemann H, Bahna SL, von Berg A, Beyer K, Bozzola M, Bradsher J, Compalati E, Ebisawa M, Guzmán MA, Li H, Heine RG, Keith P, Lack G, Landi M, Martelli A, Rancé F, Sampson H, Stein A, Terracciano L, Vieths S. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol 2010; 21 Suppl 21:1-125. [PMID: 20618740 DOI: 10.1111/j.1399-3038.2010.01068.x] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Alessandro Fiocchi
- Paediatric Division, Department of Child and Maternal Medicine, University of Milan Medical School at the Melloni Hospital, Milan 20129, Italy.
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Fiocchi A, Brozek J, Schünemann H, Bahna SL, von Berg A, Beyer K, Bozzola M, Bradsher J, Compalati E, Ebisawa M, Guzman MA, Li H, Heine RG, Keith P, Lack G, Landi M, Martelli A, Rancé F, Sampson H, Stein A, Terracciano L, Vieths S. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. World Allergy Organ J 2010; 3:57-161. [PMID: 23268426 PMCID: PMC3488907 DOI: 10.1097/wox.0b013e3181defeb9] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Allen KJ, Davidson GP, Day AS, Hill DJ, Kemp AS, Peake JE, Prescott SL, Shugg A, Sinn JKH, Heine RG. Management of cow's milk protein allergy in infants and young children: an expert panel perspective. J Paediatr Child Health 2009; 45:481-6. [PMID: 19702611 DOI: 10.1111/j.1440-1754.2009.01546.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cow's milk protein allergy is a condition commonly managed by general practitioners and paediatricians. The diagnosis is usually made in the first 12 months of life. Management of immediate allergic reactions and anaphylaxis includes the prevention of accidental food ingestion and provision of an adrenaline autoinjector, if appropriate. By contrast, the clinical course of delayed food-allergic manifestations is characterised by chronicity, and is often associated with nutritional or behavioural sequelae. Correct diagnosis of these non-IgE-mediated conditions may be delayed due to a lack of reliable diagnostic markers. This review aims to guide clinicians in the: (i) diagnostic evaluation (skin prick testing or measurement of food-specific serum IgE levels; indications for diagnostic challenges for suspected IgE- and non-IgE-mediated food allergy), (ii) dietary treatment, (iii) assessment of response to treatment, (iv) differential diagnosis and further diagnostic work-up in non-responders, (v) follow-up assessment of tolerance development and (vi) recommendations for further referral.
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Affiliation(s)
- Katrina J Allen
- Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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Abstract
Over the past decade, there has been a significant increase in the number of children and adults with eosinophilic esophagitis (EE). This recently recognized form of chronic pan-esophagitis is characterized by dense eosinophilic infiltration of the esophageal mucosa. EE is closely associated with male gender and allergic disorders, such as food allergy, eczema and asthma. The diagnosis relies on demonstration of increased numbers of eosinophils (>/= 15 per high power field) in esophageal biopsies. There is clinical overlap between EE and gastroesophageal reflux disease (GERD). Patients with EE typically present with reflux symptoms but are unresponsive to proton pump inhibitor therapy. While dysphagia, regurgitation and retrosternal pain are the clinical hallmarks of EE, many patients are asymptomatic. Treatment aims to prevent long-term complications, such as acute food bolus impaction or esophageal strictures. In childhood, treatment relies on elemental or elimination diets. Skin prick and atopy patch testing have proved useful in guiding specific dietary elimination. In adolescents and adults, broad-based elimination diets are commonly not tolerated or may be ineffective. These patients may respond to swallowed corticosteroid aerosols or other immune-modulating drugs. Further prospective clinical trials are needed to outline the most effective long-term treatment of EE.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Melbourne, Victoria, Australia.
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Abstract
AIM To examine the physical and mental health outcomes at school-age of a cohort of children who participated in a randomised clinical trial of treatments for persistent crying in infancy. METHODS Participants and parents attended for a standard physical examination and clinical mental health assessment of the children. Parents completed the Strength and Difficulties Questionnaire (SDQ), Child Health Questionnaire (CHQ), Forsyth Child Vulnerability Scale, Recent Life Events Questionnaire, RAND-36 Health Status Inventory and a study questionnaire about medical and socio-demographic characteristics. RESULTS Seventy-five of 127 (59%) traced infant-parent dyads participated. There were no significant differences in baseline demographic characteristics, infant crying or maternal stress between those who participated and those who declined. Mothers who participated had higher Edinburgh Postnatal Depression Scale scores. The study group had poorer mental health, as measured on the SDQ, than a community sample (26.3% vs. 9.9% abnormal cases, risk ratio 2.56 (confidence interval 1.72, 3.80)). Fifteen of 61 (24.6%) children who attended for the clinical mental health assessment met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for a mental disorder. In the 4 weeks preceding the assessment, the child's health limited family activities more than in a community sample (CHQ-Family Activities; P < 0.001). Parents had less time for personal needs compared with community norms (CHQ-Parent Time; P < 0.001) and were more likely to worry about their child's health (CHQ-Parent E; P < 0.001). CONCLUSION At school-age, children with a history of hospitalisation for persistent crying in infancy had a significantly higher prevalence of mental health problems and mental disorders, as compared with community samples.
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Affiliation(s)
- Mary Brown
- The University of Melbourne, Melbourne, Victoria, Australia
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Prescott SL, Smith P, Tang M, Palmer DJ, Sinn J, Huntley SJ, Cormack B, Heine RG, Gibson RA, Makrides M. The importance of early complementary feeding in the development of oral tolerance: concerns and controversies. Pediatr Allergy Immunol 2008; 19:375-80. [PMID: 18266825 DOI: 10.1111/j.1399-3038.2008.00718.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Rising rates of food allergies in early childhood reflect increasing failure of early immune tolerance mechanisms. There is mounting concern that the current recommended practice of delaying complementary foods until 6 months of age may increase, rather than decrease, the risk of immune disorders. Tolerance to food allergens appears to be driven by regular, early exposure to these proteins during a 'critical early window' of development. Although the timing of this window is not clear in humans, current evidence suggests that this is most likely to be between 4 and 6 months of life and that delayed exposure beyond this period may increase the risk of food allergy, coeliac disease and islet cell autoimmunity. There is also evidence that other factors such as favourable colonization and continued breastfeeding promote tolerance and have protective effects during this period when complementary feeding is initiated. This discussion paper explores the basis for concern over the current recommendation to delay complementary foods as an approach to preventing allergic disease. It will also examine the growing case for introducing complementary foods from around 4 months of age and maintaining breastfeeding during this early feeding period, for at least 6 months if possible.
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Affiliation(s)
- Susan L Prescott
- School of Paediatrics and Child Health Research, University of Western Australia, Perth, WA, Australia.
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Abstract
Gastro-oesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. Gastrointestinal food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. The diagnosis of food protein-induced gastrointestinal motility disorders is hampered by the absence of specific clinical features or useful laboratory markers. Gastrointestinal biopsies before commencing a hypoallergenic diet may provide the most important diagnostic clues. Early recognition is essential for the optimal management of these patients to prevent nutritional sequelae or aversive feeding behaviours. Treatment relies on hypoallergenic formulae, as well as maternal elimination diets in breast-fed infants. Further research is required to better define the pathological mechanisms and diagnostic markers of paediatric allergic gastrointestinal motility disorders. The following article will present three instructive cases followed by discussion of the clinical presentation, diagnosis, treatment and natural history of food allergic motility disorders in infancy and early childhood.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology & Clinical Nutrition Royal Children's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.
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Ho MH, Wong WH, Heine RG, Hosking CS, Hill DJ, Allen KJ. Reply. J Allergy Clin Immunol 2008. [DOI: 10.1016/j.jaci.2008.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW The primary prevention of food allergy and atopy has become a public health priority in developed countries. Although some preventive dietary interventions have entered common practice, the level of evidence underpinning these strategies varies. RECENT FINDINGS Exclusive breast-feeding and delayed introduction of complementary foods from the age of 4-6 months are key strategies in primary food allergy and atopy prevention. Maternal elimination diets during pregnancy and lactation are currently not recommended. Partially and extensively hydrolyzed formulae may confer a small preventive effect in high-risk infants. Amino acid-based formula is, however, considered a treatment formula and not recommended for primary allergy prevention. The effect of prebiotic oligosaccharides and probiotic bacteria in prevention of food allergy remains unclear and requires further investigation. Maternal fish oil supplementation during pregnancy shows promise in reducing the risk of allergic sensitization in the infant, but prospective long-term data are required. Fish oil supplementation in young infants was not effective. SUMMARY Although there is evidence for the primary dietary prevention of eczema and possible respiratory allergies, data on food allergy prevention have, so far, remained less convincing. Further prospective research is needed to clarify the effectiveness of dietary interventions in primary food allergy prevention.
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Affiliation(s)
- Ralf G Heine
- Department of Allergy and Immunology, Royal Children's Hospital, Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.
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Abstract
The prevalence of eosinophilic oesophagitis appears to be increasing in many countries, sometimes rapidly, although this may be partly due to increased disease recognition. Histological methods of assessment and diagnostic criteria vary considerably between major clinical centres. Oesophagitis with over 20 intraepithelial eosinophils per high power field is more likely to be due to allergy than gastro-oesophageal reflux induced acid-peptic mucosal injury. Typical eosinophilic oesophagitis shows involvement of the entire oesophagus, with basal cell proliferation occupying more than 50% of the thickness of the surface epithelium, and high numbers of intraepithelial eosinophils, sometimes concentrated on the surface or as contiguous clusters. Ulceration and prominent neutrophils are atypical and should suggest an alternative or co-existent disease. On endoscopy, the oesophagus may display the typical 'corrugated' mucosal appearance. Clinically, dysphagia or food impaction are the most characteristic symptoms. There is a strong association with other atopic diseases, especially asthma and eczema. To date no evidence has emerged of an increased malignancy risk. Patients with eosinophilic oesophagitis typically fail to respond to acid suppressive medications but respond well to either elemental/elimination diets or aerosolised swallowed corticosteroids. Long-term uncontrolled oesophageal eosinophilic inflammation may lead to progressive subepithelial fibrosis, potentially resulting in strictures or oesophageal narrowing.
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Affiliation(s)
- Kerryn Ireland-Jenkin
- Department of Anatomical Pathology, Royal Children's Hospital, Melbourne, Victoria, Australia
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