Continuous cow's milk protein ingestion during infancy may promote casein-specific IgG4 production

Background

Early supplementation and subsequent discontinuation of cow's milk formula (CMF) may increase the risk of cow's milk allergy in breast-fed infants, but little is known about the relationship between continuous CMF ingestion and cow's milk protein-specific immunoglobulin production.

Objective

This study aimed to clarify the aforesaid relationship in cow's milk-sensitized infants.

Methods

Using data from a randomized controlled trial of a Japanese birth cohort, we performed a subgroup analysis of participants who had ingested CMF in the first 3 days of life and exhibited a positive skin prick test response to cow's milk at age 6 months. We compared the differences in median titers of cow's milk-specific IgE, casein-specific IgE, and casein-specific IgG4 levels between participants who continued daily or intermittent CMF ingestion up to age 6 months (the "continuous group") and participants who discontinued CMF ingestion before age 6 months (the "discontinued group").

Results

From among 462 trial participants, 49 (10.6%) were included in this study (21 in the continuous group and 29 in the discontinued group). The median titer of cow's milk-specific IgE was 0.17 kUA/L (interquartile range [IQR] = <0.10 to 0.57) in the continuous group and 0.66 kUA/L (IQR = 0.49-1.18) in the discontinued group (P = .0008). The median titer of casein-specific IgE was <0.10 kUA/L (IQR = <0.10 to 0.15) in the continuous group and <0.10 kUA/L (IQR = <0.10 to 0.37) in the discontinued group (P = .51). The median titer of casein-specific IgG4 was 2.58 mgA/L (IQR = 0.77-6.73) in the continuous group and 0.09 mgA/L (IQR = 0.07-0.13) in the discontinued group (P < .0001).

Conclusion

Continuous CMF ingestion may promote casein-specific IgG4 production in cow's milk-sensitized infants.

The Age Specific Microbiome of Children with Milk, Egg, and Peanut Allergy

BACKGROUND

Immune regulation by gut microbiota is affected by dysbiosis and may precede food allergy onset. Prior studies lack comparisons stratified by age and clinical phenotype.

OBJECTIVE

The primary objective was to assess the microbiome of children with food allergy (< 3years, 3-18years) compared to similar aged children without food allergy.

METHODS

A real-world prospective cross-sectional study performed from 2014-2019 recruited children highly likely to have milk, egg or peanut allergy defined by history and serum IgE or confirmed by food challenge. 16S ribosomal RNA sequencing identified stool microbial DNA. Alpha- and beta-diversity was compared between food-allergic groups and healthy controls stratified by age. Differential abundance for non-a-priori taxa was accepted at absolute fold-change > 2 and q-value < 0.05.

RESULTS

70 patients were included(56 food-allergic;14 healthy controls). Groups were not significantly different in age, gender at birth, race, mode of delivery, breastfeeding duration, or antibiotic exposure. Younger food-allergic children had similar alpha-diversity compared to controls. Beta diversity was significantly different by age(p=0.001). There was differential abundance of several a-priori(p<0.05) taxa (including Clostridia) only in younger children. Both a-priori (including Coprococcus, Clostridia) and non-a-priori(q<0.05) Acidobacteria_Gp15,Aestuariispira, Tindallia and Desulfitispora were significant in older food-allergic children, especially with peanut allergy.

CONCLUSION

Dysbiosis associates with food allergy, most prominent in peanut-allergic older children. Younger children with and without food allergy have fewer differences in gut microbiota. This correlates with clinical observations of persistence of peanut allergy, and improved efficacy and safety of oral immunotherapy in younger children. Age under 3 should be considered when initiating therapeutic interventions.

Consumption of cow's milk formula in the nursery and the development of milk allergy

BACKGROUND

The effect of the amount of transient cow's milk formula (CMF) consumed during the first days of life on IgE-cow's milk allergy (IgE-CMA) is unknown.

METHODS

A cohort of 58 patients with IgE-CMA was identified from a large scale population-based study of 13,019 infants followed from birth. A group of 116 infants matched for sex and breastfeeding only duration (beyond the nursery period), and another random group of 259 healthy infants were used as controls. Parents were interviewed and the infants' medical records were searched to assess CMF consumption in the nursery.

RESULTS

While 96% of the mothers of the 174 infants (58 with Cow's milk allergy and 116 controls) reported on exclusive breastfeeding during the stay in the nursery, CMF consumption was documented in 96 (55%) of the infants. Of those, most (57; 59%) received one to three feedings, 20 (21%) received four to nine feedings, and 19 (20%) received ≥10 feedings. Fewer formula feeds (1-3) were significantly more common in the allergic group than ≥4 feeds (p = 0.0003) and no feeds at all (p = 0.02) compared to controls (n = 116). Of those exclusively breastfed in the nursery, 13/23 allergic infants (57%) introduced CMF at age 105-194 days (the period with highest-risk for IgE-CMA) compared to 33/98 (34%) from the random control group (n = 259) (p = 0.04).

CONCLUSIONS

Most infants end up receiving few CMF feeds in the nursery. Transient CMF in the nursery is associated with increased risk of IgE-CMA.

Mobile App/Web Platform for Monitoring Food Oral Immunotherapy in Children: Longitudinal Clinical Validation Study

BACKGROUND

Milk and egg allergies significantly impact the quality of life, particularly in children. In this regard, food oral immunotherapy (OIT) has emerged as an effective treatment option; however, the occurrence of frequent adverse reactions poses a challenge, necessitating close monitoring during treatment.

OBJECTIVE

This study aims to evaluate the ability of a new mobile/web app called OITcontrol to monitor milk and egg OIT.

METHODS

Patients undergoing milk or egg OIT were recruited and divided into 2 groups: the active group used the OITcontrol app in conjunction with standard written monitoring methods, whereas the control group relied solely on written diaries. Investigators documented hospital doses, hospital reactions, and administered treatments on the website. Patients recorded their daily allergen home-dose intake, home reactions, and administered treatments using the app. The following variables were compared between both groups: number and severity of hospital and reported home reactions, patient's adhesion to the OITcontrol app or written diary or both in terms of daily home-dose intake and home reactions recording, and treatment and dose adjustment compliance at home in case of reaction.

RESULTS

Sixteen patients were assigned to be monitored using the OITcontrol app along with additional written methods (active group), while 14 patients relied solely on a written paper diary (control group). A similar distribution was observed in terms of sex, age, basal characteristics, allergen treated in OIT, premedication, and sensitization profile. Active patients reported a comparable number of hospital and home reactions compared with the control group. In terms of recording system usage, 13/16 (81%) active patients used the OITcontrol app, while 10/14 (71%) control patients relied on the written diary. Among active patients, 6/16 (38%) used both methods, and 1 active patient used only written methods. However, control patients recorded home reactions more frequently than active patients (P=.009). Among active patients, the app was the preferred method for recording reactions (59/86, 69%), compared with the written diary (15/86, 17%) or both methods (12/86, 14%; P<.001). Treatment compliance in home-recorded reactions was similar between both groups (P=.15). However, treatment indications after an adverse reaction were more frequently followed (P=.04) in reactions recorded solely in the app (36/59, 61%) than in the written diary (29/71, 41%) or both systems (4/12, 33%). Moreover, compliance with dose adjustments after a moderate-severe reaction in home-recorded reactions was higher in the active group than in the control group (P<.001). Home reactions recorded only in the app (16/19, 84%) were more likely to follow dose adjustments (P<.001) than those recorded in the written diary (3/20, 15%) or using both methods (2/3, 67%).

CONCLUSIONS

The OITcontrol app appears to be a valuable tool for monitoring OIT treatment in children with food allergies. It proves to be a suitable method for recording daily home dose intakes and reactions, and it seems to enhance adherence to treatment indications following an adverse reaction as well as compliance with dose adjustments in home reactions. However, additional studies are necessary to comprehensively grasp the benefits and limitations of using the OITcontrol app in the management of OIT.

Pediatric oral food challenges in the outpatient setting: A single-center experience

Background

Oral food challenge (OFC) is the criterion standard for diagnosing food allergy (FA). It is important to have parameters to aid in selecting ideal OFC candidates.

Objective

We sought to characterize outcomes and predictors of OFCs for common food allergens.

Methods

We completed a retrospective chart review of all OFCs for IgE-mediated FA performed at Duke University pediatric allergy clinics from June 2017 through May 2022. Patients were deemed eligible for milk, egg, and nut OFC if testing revealed a specific IgE level not exceeding 2 kU/L and a skin prick test (SPT) resulting in a wheal size not exceeding 5 mm. Different parameters were followed for selecting candidates for baked challenge.

Results

A total of 663 OFCs were conducted on 510 patients (59% male). The most common foods challenged were peanut (26%), plain egg (23%), baked egg (8%), and milk (8%), with pass rates of 84%, 88%, 62%, and 84%, respectively. Of the patients who failed OFC, 84% had objective symptoms, 23% had multisystemic reactions, and 15% required epinephrine. Although the presence of a personal or family history of atopy or prior failed OFC was not associated with outcomes, a history of anaphylaxis (regardless of the trigger) was associated with increased risk of failure.

Conclusion

Although there are no established consensus guidelines, our study provides a benchmark illustrating that cutoffs of a specific IgE level not exceeding 2 kU/L and SPT finding not exceeding 5 mm result in a failure rate of approximately 13% for nonbaked milk, nonbaked egg, and nuts. The high rate of failed baked egg OFCs is likely related to selection bias, but our results illustrate the low negative predictive value of ovomucoid.

Single-food elimination of cow's milk as a treatment for eosinophilic esophagitis in children aged 2-18 years: A review of the literature

Cow's milk elimination (CME) is an established treatment, similar to other forms of diet therapy, for eosinophilic esophagitis (EoE). However, there is limited research to support its efficacy as a primary treatment. This review evaluated studies published in the past 10 years that assessed the outcomes after CME on histologic remission, clinical findings, and quality of life (QoL) in children aged 2-18 years with EoE. The evidence demonstrated that CME was effective at achieving histologic remission of disease in 50%-65% of children. This intervention also improved clinical symptoms seen on endoscopy and resulted in increased QoL when self-reported by children. CME can be used as a primary treatment for some children with EoE.

Epigenomic and epigenetic investigations of food allergy

As a potential link between genetic predisposition, environmental exposures, and food allergy outcomes, epigenetics has been a molecular variable of interest in ongoing efforts to understand food allergy mechanisms and outcomes. Here we review population-based investigations of epigenetic loci associated with food allergy, focusing on established clinical food allergy. We first provide an overview of epigenetic mechanisms that have been studied in cohorts with food allergy, predominantly DNA methylation but also microRNA. We then discuss investigations that have implemented epigenome-wide approaches aimed at genome-wide profiling and discovery. Such epigenome-wide studies have collectively identified differentially methylated and differentially regulated loci associated with T cell development, antigen presentation, reaction severity, and causal mediation in food allergy. We then discuss candidate-gene investigations that have honed in on Th1, Th2, T regulatory, and innate genes of a priori interest in food allergy. These studies have highlighted methylation changes in specific candidate genes as associated with T regulatory cell activity as well as differential methylation of Type 1 and Type 2 cytokine genes associated with various food allergies. Intriguingly, epigenetic loci associated with food allergy have also been explored as potential biomarkers for the clinical management of food allergy. We conclude by highlighting several priority directions for advancing population-based epigenomic and epigenetic understandings of food allergy.

Cow's milk allergy: Can oral food challenges be avoided? A probabilistic analysis based on clinical data

Introduction. The oral food challenge (OFC) for the diagnosis of cow's milk protein allergy (CMPA) poses risks and requires resources. Our objective was to assess conditions and complementary tests used to identify a high probability of CMPA. Population and methods. Secondary analysis of a study of patients seen at a unit of allergy between 2015 and 2018. Pre-testing probabilities associated with symptoms and their combinations and post-testing probabilities after skin prick testing and serum immunoglobulin E (IgE) levels were determined. Results. The data from 239 patients were assessed. A probability greater than 95% was observed for angioedema and a combination of urticaria and vomiting. Based on the cut-off points proposed by Calvani et al., the combination of vomiting with rhinitis, without angioedema, also exceeded 95%. Conclusion. A methodology is provided to identify patients in whom CMPA may be diagnosed without an OFC.

Adult-onset IgE-mediated cow's milk allergy-a rare phenotype

Cow's milk allergy has been studied extensively in infants and young children and has public health importance around the globe. We describe the clinical and demographic characteristics of 3 cases of a rare presentation of adult-onset IgE-mediated cows' milk allergy.

Reactivity to allergenic food contaminants: A study on products on the market

BACKGROUND

The frequency and severity of reactions in food-allergic consumers exposed to unintentional food allergen contamination during production is unknown. To warn allergic consumers, it has been suggested for pre-packaged foods to be precautionary labelled when the food allergen contamination may exceed the amount to which 1%-5% of the population could react (ED01-ED05). ED01 for hazelnut and milk have been estimated at 0.1 and 0.2 mg, respectively, by the Voluntary Incidental Trace Allergen Labelling (VITAL) initiative. The respective reference doses recommended by the FAO/WHO Codex consultation are 3 and 2 mg. We evaluated the reactivity to potential traces of milk and hazelnut allergens in allergen-free pre-packaged products by children affected by severe allergies to milk and hazelnuts.

METHODS

Oral Food Challenges with commercially available hazelnut-free wafer biscuits and milk-free chocolate pralines were administered to patients with severe food allergies to hazelnut and cow's milk, respectively. Contamination levels of milk or hazelnut allergens were measured using chromatographic separation interfaced with triple quadrupole mass spectrometry.

RESULTS

No hazelnut allergic patient showed allergic reactions to exposure to biscuits, nor any milk allergic patient displayed allergic reactions to the dark chocolate praline. While no hazelnut trace was detected in biscuits, the praline was found to be contaminated by milk at concentrations ranging between 8 and 35 mg total protein/kg food. In our dose model, these amounts exceeded 1.5-10 times the VITAL ED01 and reached the threshold suggested by the FAO/WHO Codex consultation.

CONCLUSIONS

Upon the consumption of food products available on the market, many patients with severe food allergies tolerate significantly higher doses of allergen than reference doses indicated in the VITAL system used for precautionary allergen labelling. These doses support the safety of the FAO/WHO recommended reference doses.

Prevalence of Parent-Reported Food Allergy in a Mexican Pre-School Population

The magnitude and relevance of food allergies in the preschool population remain unknown in most regions of Mexico and Latin America. Thus, our aim was to estimate the parent-reported prevalence of food allergies in a Mexican preschool population and to characterize their clinical diagnosis and presentation. A cross-sectional survey was conducted in Culiacán City. A validated questionnaire was utilized. A total of 810 parents responded to the questionnaire (valid response rate, 40.7%). The estimated prevalence rates (95% CI) were: "physician-diagnosed Food Allergy (FA), ever" 5.30% (3.86-7.08); "immediate-type FA, ever" 2.96% (1.91-4.38); "immediate-type FA, current" 1.60% (0.86-2.73); and food-dependent anaphylaxis 1.11% (0.51-2.01). The main food allergens were milk (0.49%), strawberries (0.37%), egg, and soy (0.25% each). Atopic diseases and a family history of allergies were significantly associated with immediate-type FA. Among "immediate-type FA, current" cases, 76.9% required emergency room visits, but the prescription of epinephrine autoinjectors was reported in one case only. The food reactions occurred at home (92.35%), in a relative's house (38.5), and at restaurants (23%). Immediate-type FA reactions requiring emergency room visits are not uncommon among the studied population. Actions like proper anaphylaxis management and the prevention of cross-contamination of foods should be encouraged.

Formula milk companies and allergy healthcare professionals in India

India is a low-middle income country with a population of 1.4 billion and home to one quarter of the world's children. Exclusive breastfeeding until 6 months and continued breastfeeding until at least 2 years as per global recommendations are common practice. The Indian government and associated organisations have strived to protect breastfeeding, which is important in a country with high under-5 mortality, malnutrition and stunting. Allergic disease is under-recognised in India, but despite the absence of a dedicated allergy medical specialty, awareness of allergy is increasing among healthcare practitioners and in the general population. In high-income countries, overdiagnosis of allergy has become recognised as an issue in recent years. Allergy healthcare professionals have also attracted criticism for close relationships with the formula industry, which appear to have contributed to excessive use of specialised formula products and undermining of breastfeeding. Specialised formula has been used unnecessarily for preventing allergy, based on fraudulent and selectively reported science; and for managing normal infant symptoms which are mislabelled as milk allergy. This forms part of a broader formula industry corporate strategy to widen the boundaries of illness in order to expand sales and markets. In India, allergic disease management is hindered by limited understanding of the disease entity among practitioners, low access to diagnostics, limited healthcare resources, high exposure to air pollution and a large, diverse population. Data specific to India on allergic disease prevalence and interpreting allergy diagnostics are incomplete. The knowledge gaps mean allergy management in India is often extrapolated from guidance developed in high-income countries with low breastfeeding rates. As the allergy specialty develops in India, local guidance and practice will need to recognise the threat that current allergy practice poses to India's normative infant feeding culture, and ensure that breastfeeding continues to be supported at all levels.

Combination of heat-killed Lactiplantibacillus plantarum YIT 0132 (LP0132) and oral immunotherapy in cow's milk allergy: a randomised controlled trial

Safer and more effective cow milk (CM)-oral immunotherapy that does not induce allergic reactions has not yet been standardised. We sought to explore the efficacy and feasibility of a combination of heat-killed Lactiplantibacillus plantarum YIT 0132 (LP0132) and oral immunotherapy for treating IgE-mediated cow milk allergy (CMA). We conducted a 24-week, double-blind, randomised (1:1), two-arm, parallel-group, placebo-controlled, phase 2 trial of LP0132 intervention for treating IgE-mediated CMA in children aged 1-18 years (n=60) from January 29, 2018 to July 12, 2019 in Tokyo, Japan. Participants were randomly assigned to the LP0132 group receiving citrus juice fermented with LP0132 or to the control group receiving citrus juice without. Both groups received low-dose slow oral immunotherapy with CM. The primary outcome was improved tolerance to CM, proven by the CM challenge test at 24 weeks. Secondary outcomes were changes in serum biomarkers of serum-specific β-lactoglobulin-IgE (sIgE) and β-lactoglobulin-IgG4 (sIgG4). Exploratory outcomes included changes in serum cytokine levels and gut microbiota composition. A total of 61 participants were included. Finally, 31 children were assigned to the LP0132 group and 30 to the control group, respectively. After the intervention, 41.4 and 37.9% of the participants in the LP0132 and control groups, respectively, showed improved tolerance to CM. In serum biomarkers after the intervention, the sIgG4 level was significantly higher, and interleukin (IL)-5 and IL-9 were significantly lower, in the LP0132 group than in the control group. In the gut microbiome, the α-diversity and Lachnospiraceae increased significantly in the LP0132 group, and Lachnospiraceae after the intervention was significantly higher in the LP0132 group than in the control group. In conclusion, low-dose oral immunotherapy with modulating gut microbiota might be a safer and more effective approach for treating cow's milk allergy.

Mediterranean Milk Ladder: Integrating a Healthy Eating Plan While Reintroducing Cow's Milk

The process of gradually reintroducing food allergens into an individual's diet is referred to as a food allergen "ladder", and the most recent edition of the original Milk Allergy in Primary (MAP) Care Guidelines, as well as the International Milk Allergy in Primary Care (IMAP), includes a shortened, improved, and international version with specific recipes, indicating the exact milk protein content, as well as the duration of heating and the temperature for each step of the ladder. Food allergen ladders are being used increasingly in clinical practice. The aim of this study was to develop a Mediterranean milk ladder based on the principles of the Mediterranean eating pattern. The protein content delivered in a portion of the final food product in each step of the ladder in the Mediterranean version corresponds to that provided in the IMAP ladder. Different recipes for the various steps were provided to increase acceptability and variety. Quantification of the total milk protein, casein content, and beta-lactoglobulin by Enzyme-linked immunosorbent assay (ELISA) could detect the gradual increase in concentrations, but the accuracy of the method was affected by the presence of the other ingredients in the mixtures. When developing the Mediterranean milk ladder, a key consideration was to reduce the amount of sugar by using limited amounts of brown sugar and substituting sugar with fresh fruit juice or honey for children aged older than one year. The proposed Mediterranean milk ladder includes principles of (a) healthy eating based on the Mediterranean diet and (b) the acceptability of foods across different age groups.

Oral Immunotherapy for Children with Cow's Milk Allergy: A Practical Approach

Cow milk allergy (CMA) is a prevalent disease in childhood. Natural history is usually favorable as CMA can disappear by school age in many subjects. Diagnosis corresponds to treatment, as an elimination diet is a solution. However, cow's milk (CM) is real food, hardly replaceable. Thus, CM reintroduction represents a demanding challenge in clinical practice. The induction of CM tolerance could be achievable using oral immunotherapy (OIT), such as the administration of increasing milk quantities until reaching tolerance. However, the OIT schedule and procedure need to be better standardized, and performance may vary widely. Therefore, the present study reports the practical experience of a third-level pediatric allergy center in managing children with CMA and submitting them to OIT. OFC and OIT are relatively safe procedures as the reaction rate is low. Almost two-thirds of the OIT subjects tolerated CM. Reactions were associated with high IgE levels. Therefore, the present experience, developed by a qualified center, may suggest and propose a practical approach for managing children with CMA. After the initial workup, including a thorough history, physical examination, and laboratory tests, OFC and, when indicated, OIT could be performed in most children with CMA.

Mutation of Signal Transducer and Activator of Transcription 5 (STAT5) Binding Sites Decreases Milk Allergen αS1-Casein Content in Goat Mammary Epithelial Cells

α_S1-Casein (encoded by the CSN1S1 gene) is associated with food allergy more than other milk protein components. Milk allergy caused by α_S1-casein is derived from cow milk, goat milk and other ruminant milk. However, little is known about the transcription regulation of α_S1-casein synthesis in dairy goats. This study aimed to investigate the regulatory roles of signal transducer and activator of transcription 5 (STAT5) on α_S1-casein in goat mammary epithelial cells (GMEC). Deletion analysis showed that the core promoter region of CSN1S1 was located at −110 to −18 bp upstream of transcription start site, which contained two putative STAT5 binding sites (gamma-interferon activation site, GAS). Overexpression of STAT5a gene upregulated the mRNA level and the promoter activity of the CSN1S1 gene, and STAT5 inhibitor decreased phosphorylated STAT5 in the nucleus and CSN1S1 transcription activity. Further, GAS site-directed mutagenesis and chromatin immunoprecipitation (ChIP) assays revealed that GAS1 and GAS2 sites in the CSN1S1 promoter core region were binding sites of STAT5. Taken together, STAT5 directly regulates CSN1S1 transcription by GAS1 and GAS2 sites in GMEC, and the mutation of STAT5 binding sites could downregulate CSN1S1 expression and decrease α_S1-casein synthesis, which provide the novel strategy for reducing the allergic potential of goat milk and improving milk quality in ruminants.

Quantification of Casein in Baked Food Products by Selective Analysis of Phosphorylated Peptides Using Fluorous Derivatization with Liquid Chromatography-Tandem Mass Spectrometry Method

Casein is one of the allergen proteins present in milk. Therefore, a quantification method for the selective analysis of casein using fluorous derivatization with LC-tandem mass spectrometry (LC-MS/MS) was developed. After two allergen proteins (α_S1-casein and β-casein) extracted from baked sugar cookies were tryptic digested, the obtained phosphorylated peptides were selectively derivatized by β-elimination with Ba(NO₃)₂ under basic condition and Michael addition with perfluoroalkylthiol (1H,1H,2H,2H-perfluorooctanethiol, PFOT). In this study, YKVPQLEIVPN(pSer)AQQR (104-119 fragment from α_S1-casein) and FQ(pSer)EEQQQTEDELQDK (33-48 fragment from β-casein) obtained by tryptic digestion were selected as target peptides. The phosphorylated serine residue in each peptide was converted to a perfluoroalkyl group by derivatization. The obtained fluorous-derivatized peptides were analyzed by LC-MS/MS, to which a fluorous LC column was connected. Therefore, it was possible to analyze casein without being affected by the matrix components in the baked food sample. When the present method was applied to cookies with arbitrary amounts of α_S1-casein and β-casein, the obtained quantification values were in good agreement with the arbitrary amounts spiked. The quantification limits of α_S1- and β-casein in cookie analysis were 246 and 152 ng/g, respectively. Hence, this method can be used to analyze trace amounts of allergen proteins present in the baked food.

Case Reports of Cow's Milk Protein Allergy Presenting as Delayed Passage of Meconium With Early Onset Infant Constipation

A cellular proliferation to milk allergens has been found in the cord blood cells of neonates. While this reflects a sensitivity during the fetal life, its clinical significance and disease, particularly its unconventional presentations, have remained largely unrecognized by care providers. Here, we report three cases of infants whose mothers consumed dairy products during pregnancy, who developed a severely constipated pre- and postnatal bowel. The passage of meconium was significantly delayed with subsequent early-onset infant constipation that was intractable to conventional therapies but remitted when milk proteins were withheld, recurred when milk proteins were reintroduced, and resolved again when switched to an extensively hydrolyzed or amino acid-based infant formula. Based on this and other observations, it is believed that these infants must have initiated and/or developed cow's milk protein allergy prenatally during fetal life. We suggest that a 2-week trial of cow's milk protein avoidance be applied to these neonate infants with early-onset constipation before an unnecessary invasive work-up for Hirschsprung disease and others is initiated per the current guidelines.

Chronic Milk-Dependent Food Protein-Induced Enterocolitis Syndrome in Children from West Pomerania Region

Characteristics of chronic milk-dependent food protein-induced enterocolitis syndrome (FPIES) in children from the region of Western Pomerania were studied. Prospectively, 55 children were diagnosed at a median of 2.2 months. The open food challenges (OFC), morphologies, milk-specific IgE (sIgE) (FEIA method, CAP system), and skin prick tests (SPTs) were examined. Vomiting and diarrhea escalated gradually but quickly led to growth retardation. Of the infants, 49% had BMI < 10 c, 20% BMI < 3 c; 25% had anemia, and 15% had hypoalbuminemia. During the OFCs we observed acute symptoms that appeared after 2-3 h: vomiting diarrhea and pallor. A total of 42% children required intravenous hydration. Casein hydrolysates or amino acids formulae (20%) were used in treatment. In 25% of children, SPT and milk sIgE were found, in 18%-other food SPTs, and in 14% allergy to other foods. A transition to IgE-dependent milk allergy was seen in 3 children. In the twelfth month of life, 62% of children had tolerance to milk, and in the twenty-fifth month-87%. Conclusions. Chronic milk-dependent FPIES resolves in most children. By the age of 2 children are at risk of multiple food sensitization, and those who have milk sIgE are at risk to transition to IgE-mediated milk allergy. Every OFC needs to be supervised due to possible severe reactions.

Efficacy and Safety of Baked Milk Oral Immunotherapy in Children with Severe Milk Allergy: A Randomized, Double-blind, Placebo-controlled Phase 2 Trial

BACKGROUND

Cow's milk allergy is the most common food allergy in young children and has no current treatment. Oral immunotherapy studies to date have shown efficacy but high rates of adverse reactions.

OBJECTIVE

We sought to evaluate the safety and efficacy of baked milk oral immunotherapy (BMOIT) in baked milk allergic children.

METHODS

Participants (3-18 years) were randomized to receive BMOIT or placebo for 12 months. Efficacy was assessed by double-blind placebo-controlled food challenge after 12 months of treatment. Safety, quality of life, and mechanistic parameters were also evaluated.

RESULTS

11/15 (73%) of the BMOIT participants reached the primary endpoint, tolerating 4044 mg of baked milk protein after 12 months of OIT, compared to 0/15 (0%) on placebo. The median maximal tolerated dose (MTD) and median change from baseline was significantly higher in the BMOIT group compared to placebo (median MTD 4044mg vs 144mg; p=0.001; median change in MTD of 3900mg vs 0mg, p=0.0001). Dose-related reactions were common but >95% in both groups were mild. There was no significant change in CM- or beta lactoglobulin-IgE from baseline for either group. CM-sIgG4 did significantly increase and casein IgE decreased in the BMOIT group. For proxy-reported food allergy quality of life, there was a significant difference in the emotional impact domain only with more improving while on placebo compared BMOIT. The majority of children and adolescents in the BMOIT group directly reported improvement in at least one domain.

CONCLUSION

BMOIT was well tolerated and induced a substantial level of desensitization after 12 months of treatment.

Clinical presentation and management of food protein-induced enterocolitis syndrome in 113 Swedish children

BACKGROUND

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy causing severe acute gastrointestinal symptoms and lethargy, mainly affecting infants and young children. There are geographic variations in its clinical features. This study aimed to describe the clinical characteristics and management of FPIES in Swedish children.

METHODS

The study included children who presented with acute FPIES during 2008-2017. All Swedish pediatric departments (n = 32) were invited to report their known patients. Data were collected through chart reviews and interviews with parents.

RESULTS

Eighteen pediatric departments contributed, and 113 patients were included. Most had a family history of atopy (74%), and 51% had an atopic disease. Common trigger foods were cow's milk (26%), fish (25%), oat (22%), and rice (8%). Most patients (85%) reacted to a single food. The median age at first reaction was 3.9 months for cow's milk and 6.0 months for other foods (p < 0.001, range 1.0 month to 9 years). Repetitive vomiting (100%), lethargy (86%), and pallor (61%) were common symptoms; 40% had diarrhea. Sixty percent visited the emergency department, and 27% of all patients were hospitalized. Most patients were diagnosed clinically (81%). Specific IgE for the trigger food was positive in 4/89 tested patients (4%), and skin prick test for the trigger food was positive in 1/53 tested patients (2%).

CONCLUSIONS

In our Swedish study of 113 children, cow's milk, fish, and oat were the commonest trigger foods. Most patients reacted to a single food, and IgE sensitization was rare.

Skimmed Milk Applied as a Phytopharmaceutical Product: A Risk for Allergic Populations?

Milk allergy is among the most common food-related allergies. Milk-based products are recognized as plant protection products (PPPs) in several countries as alternatives to synthetic pesticides. The potential health risk for allergic workers, as well as the general population, is yet to be assessed. An investigation was conducted in the Vaud Canton of Switzerland, where milk-based products are sprayed by helicopter over vineyards. Air lactose concentration was measured at 14 locations via 25 mm IOM Multidust samplers. Residual lactose concentration was measured on the surface of leaves over 7 days following spraying. Surface contamination downwind from the treated area was estimated through computer-based modeling using AgDRIFT^® software. The average milk protein concentration inside and outside the vineyard was 0.47 and 0.16 µg/m³, respectively. Milk residues persisted on the leaf surface for an average of three days. Modelling results revealed an estimated order of magnitude of 0.1-0.5 µg/m³ in milk proteins within one hour after the treatment in the close vicinity of the treated area. Our results reveal that the potential exposure to milk proteins in and around helicopter-treated vineyards is not negligible and that prevention messages targeted to individuals with severe allergies should be considered.

Infantile Inflammatory Bowel Disease in a Three-Month-Old-Boy

Very early-onset inflammatory bowel disease (VEO-IBD) and infantile IBD occur in children aged less than six years and less than two years, respectively. Since childhood-onset IBD seems to be a more aggressive and rapidly progressive disease than adult-onset IBD, it should therefore be diagnosed and treated immediately. Here, we report a case of infantile IBD in a three-month-old infant with clinical and biochemical manifestations. The diagnosis was confirmed with histopathological evidence. The patient had been treated successfully with both mesalazine and prednisolone and with mesalazine alone on follow-up.

Bos d 11 in baked milk poses a risk for adverse reactions in milk-allergic patients

BACKGROUND

Patients are commonly challenged with foods containing baked milk, for example muffins, yet little is known about the specific allergen content of muffins used in milk challenges or of the effect that baking has on allergenicity.

OBJECTIVE

Our objective was to compare the levels of major milk allergens in uncooked and baked muffins using monoclonal immunoassays and IgE antibody binding before and after baking.

METHODS

Uncooked and baked muffins were prepared using recipes from Mount Sinai and Imperial College. Allergen levels were compared by ELISA for Bos d 5 (β-lactoglobulin) and Bos d 11 (β-casein). IgE reactivity was assessed using sera from milk-sensitized donors in direct binding and inhibition ELISA.

RESULTS

Bos d 5 was reduced from 680 µg/g in uncooked muffin mix to 0.17 µg/g in baked muffins, representing a >99% decrease after baking. Conversely, Bos d 11 levels in baked muffin remained high and only decreased by 30% from a mean of 4249 µg/g in uncooked muffin mix to 2961 µg/g when baked (~181 mg Bos d 11 per muffin). Baked muffins retained ~70% of the IgE binding to uncooked muffin mix. Baked muffin extract inhibited IgE binding to uncooked muffin mix by up to 80%, demonstrating retention of in vitro IgE reactivity.

CONCLUSIONS AND CLINICAL RELEVANCE

High levels of Bos d 11 in baked muffins pose a risk for adverse reactions, especially in patients who have high anti-casein IgE antibodies.

Bovine β-lactoglobulin-induced passive systemic anaphylaxis model using humanized NOG hIL-3/hGM-CSF transgenic mice

Food allergy is a common disease caused by intake of allergen-containing foods, such as milk, eggs, peanuts and wheat. Systemic anaphylaxis is a severe hypersensitive allergic reaction resulting from degranulation of mast cells or basophils after cross-linking of surface high-affinity IgE receptors (Fcε-RI) with allergen-specific IgE and allergens. In this study, we developed a novel human mast cell/basophil-engrafted mouse model that recapitulates systemic anaphylaxis triggered by β-lactoglobulin (BLG), a major allergen found in cow's milk. Human CD34+ hematopoietic stem cells were transferred into NOG (non-Tg) or NOG hIL-3/hGM-CSF transgenic (Tg) mice. After 14-16 weeks, bovine BLG-specific human IgE was intravenously injected into humanized mice, followed by intravenous or oral bovine BLG exposure 1 day later. Body temperature in Tg, but not in non-Tg, mice gradually decreased within 10 min, and 80% of Tg mice died within 1 h by intravenous BLG exposure. Serum histamine levels and anaphylaxis scores in Tg mice were markedly increased compared to non-Tg mice. Furthermore, these allergic symptoms were significantly inhibited by epinephrine treatment of the Tg mice. Therefore, the current NOG hIL-3/hGM-CSF Tg mouse model may be useful for development of novel anaphylaxis drugs for treatment of food allergies and for safety assessment of low-allergenicity extensively hydrolyzed cow's milk whey protein-based infant formulas.

Milk allergy most burdensome in multi-food allergic children

BACKGROUND

Food allergy is a substantial health burden, which disproportionately affects children. Among children with food allergy, as many as 70% have multiple food allergies. Whereas the overall burden of food allergy on quality of life has been described, little is known about the burden of individual allergens. We aimed to examine the perception of burden among families with multiple food-allergic children.

METHODS

Parents of children with 1 + children with multiple food allergies including milk responded to online questions, including both open-ended and closed-ended questions on food allergy-related burdens of time, financial costs, social restrictions, and emotional demands.

RESULTS

Overall, 64 children (69.8% boys) of whom (73.0%) most were aged 10 and younger were included. Most had been diagnosed with food allergy in infancy and by a (pediatric) allergist. Other common allergies included peanut (65.6%), tree nuts (57.8%), egg (76.6%), and sesame (31.3%). Quantitatively, milk allergy was reported as carrying the most burden, including most socially limiting (81.5%), requiring the most planning (75.9%), causing the most anxiety (68.5%), most challenging to find "safe" or allergy-friendly foods (72.2%), and costly (81.5%). Qualitatively, we identified five themes that captured burdens associated with costs, marketing of milk products to children, risk of cross-contamination, ubiquity of milk/dairy and public confusion with lactose intolerance, and an unwillingness of others to accommodate the allergy.

CONCLUSION

Parents whose children have multiple food allergies, including milk, report milk as the allergy associated with the greatest time, financial, social, and emotional burdens.

Randomized trial of early infant formula introduction to prevent cow's milk allergy

BACKGROUND

Previous research has produced conflicting evidence on the preventive effects of early introduction of cow's milk protein on cow's milk allergy (CMA).

OBJECTIVE

Through a randomized controlled trial, we sought to determine whether the early introduction of cow's milk formula (CMF) could serve as an effective strategy in the primary prevention of CMA in a general population.

METHODS

We recruited newborns from 4 hospitals in Okinawa, Japan. Participants were randomly allocated to ingest at least10 mL of CMF daily (ingestion group) or avoid CMF (avoidance group) between 1 and 2 months of age. In the avoidance group breast-feeding was supplemented with soy formula as needed. Oral food challenge was performed at 6 months of age to assess CMA development. Continuous breast-feeding was recommended for both groups until 6 months of age.

RESULTS

We identified 504 infants for randomization into the 2 groups. In all, the parents of 12 participants declined to receive the intervention, and the study sample comprised 491 participants (242 in the ingestion group and 249 in the avoidance group) for a modified intention-to-treat analysis. There were 2 CMA cases (0.8%) among the 242 members of the ingestion group and 17 CMA cases (6.8%) among the 249 participants in the avoidance group (risk ratio = 0.12; 95% CI = 0.01-0.50; P < .001). The risk difference was 6.0% (95% CI = 2.7-9.3). Approximately 70% of the participants in both groups were still being breast-fed at 6 months of age.

CONCLUSIONS

Daily ingestion of CMF between 1 and 2 months of age prevents CMA development. This strategy does not compete with breast-feeding.

Blood or skin: what is best in predicting cow's milk allergy diagnosis?

Summary

Cut-off values for both skin prick tests (SPT) and specific IgE (sIgE) levels for predicting cow´s milk allergy (CMA) diagnosis are not universally defined. This study is a retrospective analysis of consecutive children (0-18 years-old) with suspected CMA tested with SPT and sIgE for cow's milk (CM) and its fractions between 2016-2017. CMA diagnosis was defined by a positive oral food challenge or a highly suggestive clinical history of CMA and SPT and/or sIgE positive to CM and/or its fractions. One hundred and five patients were included, 58% males with a median age of 2.5 (P25-P75:1-6) years and the diagnosis was confirmed in 83 patients (79%). The variables associated with CMA diagnosis were SPT with CM (p minor 0,05) and casein (p minor 0,05) and all sIgE to CM and its fractions (alfa Lactalbumin, beta Lactoglobulin and casein; p minor 0,05 for all). Optimal cut39 off points (Youden's index) for CMA diagnosis were, for the mean wheal diameter, to CM milk of 4.5mm and to casein of 3mm. For sIgE levels the optimal cut-off points were: for CM of 4.36 kUA/L, alfa-lactalbumin of 1.6 kUA/L, beta-lactoglobulin of 1.7 kUA/L and for casein of 2.6 kUA/L. The role of SPT and sIgE levels to cow´s mlik and its fractions is unequivocal in CMA follow-up. Moreover, sIgE levels seem to be more discriminatory than SPT.

Oral Immunotherapy (OIT): A Personalized Medicine

Oral Immunotherapy (OIT), a promising allergen-specific approach in the management of Food Allergies (FA), is based on the administration of increasing doses of the culprit food until reaching a maintenance dose. Each step should be adapted to the patient, and OIT should be considered an individualized treatment. Recent studies focused on the standardization and identification of novel biomarkers in order to correlate endotypes with phenotypes in the field of FA.

Effect of thermal and microwave processing on secondary structure of bovine β-lactoglobulin: A molecular modeling study

Milk allergy is known to cause severe allergic reactions in hypersensitive patients, especially in infants and children. β-Lactoglobulin is one of the major allergens in bovine milk. The influence of thermal and microwave processing on the structural deviations of β-lactoglobulin protein have been studied using molecular modeling techniques. The structural deviations are studied using root mean square deviations, radius of gyration, dipole moment, and solvent accessible surface area. STRIDE analysis showed significant changes in the β-lactoglobulin, especially when oscillating electric fields were applied along with heat. Root mean square fluctuations (RMSF) has been assessed for known epitopes in the β-lactoglobulin molecule. This showed that when the protein is exposed to certain thermal stress, it compacts by burying hydrophobic residues in the core. However, few allergic epitope residues also exhibit increased RMSF leading to higher reactive sites on the surface of the protein molecule. PRACTICAL APPLICATIONS: This study showed that molecular modeling can be used to gain valuable insights regarding the structural changes during processing. In the future, with more computational capacity, it can be used to make comparison between results obtained from simulations and real-time experiments. The current techniques used in food industries such as Nuclear Magnetic Resonance Imaging, Fourier Transformation Infrared Spectroscopy, X-ray diffraction can analyze pre- and post-processing effects. Hence, it become necessary to understand the changes that takes place during the processing techniques. Molecular dynamic simulation could be a useful technique in analyzing the changes occurring during the processing.

Outcome of oral immunotherapy for persistent cow's milk allergy from 11 years of experience in Finland

BACKGROUND

The safety and efficacy of long-term milk oral immunotherapy (OIT) in Finnish children with persistent cow's milk allergy (CMA) were evaluated in an open-label, non-randomized study.

METHODS

During the 11-year study, 296 children aged 5 years or older with immunoglobulin E (IgE)-mediated CMA started milk OIT. Follow-up data were collected at three time points: the post-buildup phase, 1 year thereafter, and at the cross-sectional long-term follow-up between January 2016 and December 2017. Patients were divided according to baseline milk-specific IgE (sIgE) level and by the amount of milk consumption at the long-term follow-up. The high-dose group consumed ≥2 dL of milk daily, while the failure group consumed <2 dL of milk or were on a milk-avoidance diet.

RESULTS

Out of the initial study group, 244/296 (83%) patients participated in the long-term follow-up. Among these patients, 136/244 (56%) consumed ≥2 dL of milk daily. The median follow-up time was 6.5 years. Of the recorded markers and clinical factors, the baseline milk sIgE level was most associated with maintaining milk OIT (P < 0.001). Respiratory symptoms in the post-buildup phase increased the risk of treatment failure (OR 3.5, 95% CI: 1.5-8.1, P = 0.003) and anaphylaxis (OR 14.3, 95% CI: 1.8-114, P = 0.01).

CONCLUSION

More than half of the patients were able to maintain the targeted milk dose in their daily diet. Baseline milk sIgE level and reactivity during the early treatment stage strongly predicted the long-term outcome and safety of milk OIT.

Brazilian artisanal ripened cheeses as sources of proteolytic lactic acid bacteria capable of reducing cow milk allergy

AIM

The objective was to obtain lactic acid bacteria (LAB) capable of hydrolysing immunoreactive proteins in milk, to optimize the hydrolysis, to determine the proteolysis kinetics and to test the safety of the best hydrolytic strain.

METHODS AND RESULTS

Brazilian cheese was used as source of LAB capable of hydrolysing main milk allergens. Proteolytic isolates were submitted to RAPD-PCR for the characterization of clonal diversity. Optimized hydrolysis was strain and protein fraction dependent. 16S rDNA sequencing identified three proteolytic strains: Enterococcus faecalis VB43, that hydrolysed α_S1 -, α_S2 - and β-caseins, α-lactalbumin and β-lactoglobulin (partial hydrolysis), and Pediococcus acidilactici VB90 and Weissella viridescens VB111, that caused partial hydrolysis of α_S1 - and α_S2 -caseins. Enterococcus faecalis VB43 tested negative for virulence genes asa1, agg, efaA, hyl, esp, cylL_L and cylL_S but positive for genes ace and gelE. Ethylenediamine tetra-acetic acid inhibited the proteolysis, indicating that the main proteases of E. faecalis VB43 are metalloproteases.

CONCLUSION

Brazilian artisanal cheese is a good source of LAB capable of hydrolysing allergenic proteins in milk. One isolate (E. faecalis VB43) presented outstanding activity against these proteins and lacked most of the tested virulence genes.

SIGNIFICANCE AND IMPACT OF THE STUDY

Enterococcus faecalis VB43 presents good potential for the manufacture of hypoallergenic dairy products.

Cow's Milk Allergy in Infancy and Later Development of Juvenile Idiopathic Arthritis: A Register-Based Case-Control Study

We examined the association between cow's milk allergy (CMA) and juvenile idiopathic arthritis (JIA). The material for this case-control study was collected from national registers of all children born in Finland between 2000 and 2010 and diagnosed with JIA (n = 1,298) and age-, sex-, and place-matched controls (n = 5,179). We identified 235 children with CMA; 66 of these children also had JIA. A conditional logistic regression analysis was performed to evaluate the association between CMA and JIA and to test whether exposure to antibiotics would be a covariate for this association. In boys (but not in girls), a diagnosis of CMA and the use of hypoallergenic formula in infancy were associated with the later development of JIA (odds ratio = 2.4, 95% confidence interval: 1.6, 3.6). The association was most evident in boys who were diagnosed with JIA before age 3 years or diagnosed with CMA with predominantly gastrointestinal symptoms. There was no statistically significant additive interaction between CMA and antibiotic exposure in the later development of JIA. These associations may reflect impaired maturation of intestinal immunity and integrity in boys with a risk of JIA. Predisposing factors related to JIA pathogenesis seem to display a sex-linked disparity.

Mechanistic correlates of clinical responses to omalizumab in the setting of oral immunotherapy for milk allergy

BACKGROUND

In our recent clinical trial, the addition of omalizumab to oral immunotherapy (OIT) for milk allergy improved safety, but no significant clinical benefit was detected.

OBJECTIVE

We sought to investigate mechanisms by which omalizumab modulates immunity in the context of OIT and to identify baseline biomarkers that predict subgroups of patients most likely to benefit from omalizumab.

METHODS

Blood was obtained at baseline and multiple time points during a placebo-controlled trial of OIT for milk allergy in which subjects were randomized to receive omalizumab or placebo. Immunologic outcomes included measurement of basophil CD63 expression and histamine release and casein-specific CD4⁺ regulatory T-cell proliferation. Biomarkers were analyzed in relationship to measurements of safety and efficacy.

RESULTS

Milk-induced basophil CD63 expression was transiently reduced in whole blood samples from both omalizumab- and placebo-treated subjects. However, IgE-dependent histamine release increased in washed cell preparations from omalizumab- but not placebo-treated subjects. No increase in regulatory T-cell frequency was evident in either group. Subjects with lower rates of adverse reactions, regardless of arm, experienced better clinical outcomes. Pre-OIT basophil reactivity positively associated with occurrence of symptoms during OIT, whereas the baseline milk IgE/total IgE ratio correlated with the likelihood of achieving sustained unresponsiveness. A combination of baseline basophil and serologic biomarkers defined a subset of patients in which adjunctive therapy with omalizumab was associated with attainment of sustained unresponsiveness and a reduction in adverse reactions.

CONCLUSIONS

Combining omalizumab therapy with milk OIT led to distinct alterations in basophil reactivity but not T-cell responses. Baseline biomarkers can identify subjects most likely to benefit from adjunctive therapy with omalizumab.

Side effects and their impact on the success of milk oral immunotherapy (OIT) in children

Oral immunotherapy (OIT) has been introduced as a new immune-modulating treatment under investigation for food allergies. The aim of our study was to evaluate the success of OIT in a cohort of children with milk allergy. These children underwent OIT in a clinical practice and were followed for up to ten years. The secondary endpoint was to describe the main adverse events during OIT and compare them to those reported in the literature.

Eighty-two milk-allergic children started OIT. According to the OIT endpoint reached after one year, all of the children enrolled in the study were divided into four groups: complete desensitization; partial desensitization; step down; and stop groups. Any adverse events that occurred during OIT were also recorded.

Of the 82 patients, eight were recruited in the last months of 2010 so they were still ongoing at the end of the study. For that reason, they were excluded from the analysis. The majority (73%) of the 74 children evaluated (51 boys, 23 girls; median age, 7 years; age range, 2–18 years; specific serum IgE for cow’s milk, 36 KUA/L [range, 3–100 KUA/L]; milk SPT wheal diameter, 7 mm [range, 2–15 mm]) reached complete (58.1%) or partial (14.9%) desensitization, 9.4% were subjected to step down. The remaining 17.6% of the children discontinued OIT because of the occurrence of chronic gastroenteric (GE) symptoms (46.1%) or acute asthma (15.3%) following milk intake.

In agreement with the literature, we found that chronic GE symptoms was the main reason for OIT discontinuation. OIT represents a valid tool for the treatment of food allergies in children; however, the risk of potential adverse reactions, both IgE- and non-IgE-mediated, should be discussed with parents prior to the initiation of OIT.

Generation of β-lactoglobulin-modified transgenic goats by homologous recombination

β-Lactoglobulin (BLG) is a dominant allergen present in the milk of goats and other ungulates, although it is not found in human breast milk. Thus, the presence of BLG restricts the consumption of goat's milk by humans. In the present study, we examined whether the disruption of the BLG gene in goats by homologous recombination (HR) reduced BLG content in goat's milk and decreased the allergic response to milk. In one approach, exon 2 of the BLG gene was efficiently targeted using HR with a BLG knockout vector. In a second approach to disrupt BLG gene expression and drive exogenous human α-lactalbumin (hLA) gene expression, two hLA knock-in constructs were used to target exons 1-4 of the BLG gene via HR, and expression of hLA was then confirmed in goat mammary epithelial cells in vitro. The recombinant clones from both approaches were then used for somatic cell nuclear transfer, generating two transgenic goats possessing a BLG knockout allele or site-specific hLA integration allele. Milk assays demonstrated a reduction in BLG levels in both the BLG knockout and hLA knock-in goats; furthermore, hLA was present in the hLA knock-in goat's milk. Allergenic analysis in mice indicated that the transgenic goat's milk was less allergenic than wild-type goat's milk. These results support the development of gene-targeted animals as an effective tool for reducing allergic reactions to milk and improving nutrition.

Early-life antibiotic use and subsequent diagnosis of food allergy and allergic diseases

BACKGROUND

Antibiotic use in early life has been linked to disruptions in the microbiome. Such changes can disturb immune system development. Differences have been observed in the microbiota of children with and without allergies, but there have been few studies on antibiotic use and allergic disease.

OBJECTIVE

We evaluated associations of early-life antibiotic use with subsequent occurrence of food allergy and other allergies in childhood using electronic health record data.

METHODS

We used longitudinal data on 30 060 children up to age 7 years from Geisinger Clinic's electronic health record to conduct a sex- and age-matched case-control study to evaluate the association between antibiotic use and milk allergy, non-milk food allergies, and other allergies. For each outcome, we estimated conditional logistic regression models adjusting for race/ethnicity, history of Medical Assistance, and mode of birth delivery. Models were repeated separately for penicillins, cephalosporins and macrolides.

RESULTS

There were 484 milk allergy cases, 598 non-milk food allergy cases and 3652 other allergy cases. Children with three or more antibiotic orders had a greater odds of milk allergy (Odds Ratio; 95% Confidence interval) (1.78; 1.28-2.48), non-milk food allergy (1.65; 1.27-2.14), and other allergies (3.07; 2.72-3.46) compared with children with no antibiotic orders. Associations were strongest at younger ages and differed by antibiotic class.

CONCLUSIONS AND CLINICAL RELEVANCE

We observed associations between antibiotic orders and allergic diseases, providing evidence of a potentially modifiable clinical practice associated with paediatric allergic disease. Differences by antibiotic class should be further explored, as this knowledge could inform paediatric treatment decisions.

Low serum biotin in Japanese children fed with hydrolysate formula

BACKGROUND

Given that nutritional biotin deficiency in Japanese infants has been reported, a straightforward method for estimating biotin level is needed. The biotin content in infant formula, breast milk, and the sera of infants fed with various types of formula were measured using avidin-binding assay.

METHODS

A commercially available ELISA kit was used for the measurement of biotin in 54 types of formula, including hydrolysate formulas for milk allergy, as well as in breast milk and in the sera of 27 infants fed with these formulas.

RESULTS

The biotin content reached the recommended value in only five formulas. All of the hydrolysate formulas and more than half of the special formulas contained biotin <0.1 μg/dL. Serum biotin was low in infants fed only with the hydrolysate formulas, and one of them had alopecia related to biotin deficiency.

CONCLUSION

While many were asymptomatic, infants fed with formulas lacking biotin are at risk of developing symptomatic disease. The addition of biotin to breast milk substitutes was finally approved in the middle of 2014, however pediatricians in Japan should still be vigilant with regard to nutritional biotin deficiency in infants for the time being.

Probiotic Dahi containing Lactobacillus acidophilus and Bifidobacterium bifidum modulates immunoglobulin levels and cytokines expression in whey proteins sensitised mice

BACKGROUND

Cow milk allergy is the most common food allergy in children. So far, no effective treatment is available to prevent or cure food allergy. This study investigated whether orally administrated probiotics could suppress sensitisation in whey proteins (WP)-induced allergy mouse model. Two types of probiotic Dahi were prepared by co-culturing Dahi bacteria (Lactococcus lactis ssp. cremoris NCDC-86 and Lactococcus lactis ssp. lactis biovar diacetylactis NCDC-60) along with selected strain of Lactobacillus acidophilus LaVK2 and Bifidobacterium bifidum BbVK3. Mice were fed with probiotic Dahi (La-Dahi and LaBb-Dahi) from 7 days before sensitisation with WP, respectively, in addition to milk protein-free basal diet, and control group received no supplements.

RESULTS

Feeding of probiotic Dahi suppressed the elevation of whey proteins-specific IgE and IgG response of WP-sensitised mice. In addition, sIgA levels were significantly (P < 0.001) increased in intestinal fluid collected from mice fed with La-Dahi. Production of T helper (Th)-1 cell-specific cytokines, i.e. interferon-γ (IFN-γ), interleukin (IL)-12, and IL-10 increased, while Th2-specific cytokines, i.e. IL-4 decreased in the supernatant of cultured splenocytes collected from mice fed with probiotic Dahi as compared to the other groups. Moreover, the splenic mRNA levels of IFN-γ, interleukin-10 were found to be significantly increased, while that of IL-4 decreased significantly in La-Dahi groups, as compared to control groups.

CONCLUSION

Results of the present study indicate that probiotic Dahi skewed Th2-specific immune response towards Th1-specific response and suppressed IgE in serum. Collectively, this study shows the potential use of probiotics intervention in reducing the allergic response to whey proteins in mice. © 2015 Society of Chemical Industry.

recombinant protein U-Omp16 abrogates the IgE-mediated milk allergy

Food allergies are increasingly common disorders and no therapeutic strategies are yet approved. The unlipidated Omp16 (U-Omp16) is the outer membrane protein of 16 kDa from B. abortus and possesses a mucosal adjuvant property. In this study, we aimed to examine the U-Omp16 capacity to abrogate an allergen-specific Th2 immune response when it is administered as an oral adjuvant in a mouse model of food allergy.   Balb/c mice were sensitized with cholera toxin and cow's milk proteins (CMP) by gavage and simultaneously treated with U-Omp16 and CMP. Oral challenge with CMP was performed to evaluate the allergic status of mice. Symptoms, local (small bowel cytokine and transcription factor gene expression) and systemic (specific isotypes and spleen cell-secreted cytokines) parameters, and skin tests were done to evaluate the immune response. We found that the oral administration of U-Omp16 with CMP during sensitization dampened the allergic symptoms, with negativization of immediate skin test and increased skin DTH response. Serum specific IgE and IL-5 were inhibited and a Th1 response was promoted (specific IgG2a antibodies and CMP-induced IFN-γ secretion). We found at the mucosal site an inhibition of the gene expression corresponding to IL-13 and Gata-3, with an induction of IFN-γ and T-bet. These results indicated that the oral administration of U-Omp16 significantly controlled the allergic response in sensitized mice with a shift of the balance of Th1- and Th2-T cells toward Th1 predominance. These findings suggest that U-Omp16 may be useful as a Th1-directing adjuvant in an oral vaccine.

Nutritional and Therapeutic Characteristics of Camel Milk in Children: A Systematic Review

INTRODUCTION

Camel milk is the closest to a human mother's milk. Camel milk is different from other milks, however, having low sugar and cholesterol, high minerals (sodium, potassium, iron, copper, zinc and magnesium, and vitamin C). The milk is considered have medicinal characteristics as well. This systematic review is aimed at determining and reporting nutritional values and medicinal characteristics of camel milk in children.

METHODS

The search strategy of the current review is "(camel AND milk) AND (autism OR food allergy OR milk allergy OR children OR diarrhea." The search was conducted via PubMed, Scopus, and Google scholar. Also two Persian scientific databases (SID and Iranmedex) and international congresses were investigated. Full-text papers and abstracts on the topic of camel milk, evaluating nutritional value and medicinal properties, were included in this systematic review.

RESULTS

Out of the 472 records found in the resources, 35 related studies were included in the final analysis. The result showed that camel milk is highly nutritious and is safe for consumption by children.

CONCLUSION

It seems that many researchers did not follow a specific guideline for reporting and confirming the therapeutic properties of camel milk in children, but there is evidence denoting the importance, trials, and investigations of its usability and benefits. Camel milk as a supplemental treatment seems less invasive and costly than specialist care, medications, alternative treatments, and behavioral interventions. Based on our findings, camel milk is safer for children, effective in the treatment of autism, improves general well-being, promotes body natural defenses, is a good nutritional source, and can helps the daily nutritional needs of humans.

Cow's Milk Allergy in Preterm Infant with Bronchopulmonary Dysplasia

Cow's milk allergy is frequent in the first year of life. The symptoms may start during the first weeks of life, and may be cutaneous (50-60%), gastrointestinal (50-60%) or respiratory (20-30%), often involving more than one organ system. In this report, we describe a case of cow's milk allergy in a preterm infant in whom rectal bleeding and respiratory symptoms resolved with the introduction of an extensively hydrolyzed formula. Occurrence of the respiratory symptoms of this disorder in a preterm infant with bronchopulmonary dysplasia may cause re-hospitalization after discharge.

The significance of allergic contact urticaria to milk in children with cow's milk allergy

BACKGROUND

Cow's milk allergy (CMA) is the most common food allergy in infancy. Food allergy is generally triggered through ingestion, but can also be triggered through skin contact. We investigated the incidence and the clinical significance of cow's milk protein (CMP)-induced contact urticaria in individuals with CMA with and without atopic dermatitis (AD).

METHODS

A total of 157 children of whom 133 were diagnosed with CMA were participated. The study was based on observational data gathered in the course of patient care, including a skin prick test and a 'finger test', in which cow's milk is applied on the cheek by a physician's finger to detect contact urticaria.

RESULTS

Eighty nine of 133 patients (66.9%) had IgE-mediated CMA. Forty of these 89 (44.9%) tested positive in the finger test. Family atopy was higher in those with positive contact urticaria [21/40 (52.5%) vs. 14/49 (28.5%), p = 0.029]. Patients with positive vs. negative CMP contact urticaria had higher incidence of multiple food allergies [20 of 40 (50%) vs. 7/49 (14.3%), p < 0.004]. IgE-mediated CMA patients with AD had statistically higher CMP allergic contact urticaria compared to patients without AD [71% (15/21) vs. 37% (25/68), p = 0.0064]. Children with non-IgE milk allergy and healthy control group did not have contact urticaria to CMP.

CONCLUSION

CMP contact urticaria exists only in patients with IgE-mediated CMA. A 'finger test' to CMP should be part of the evaluation of CMA patients, and positivity suggests the potential for multiple food allergies, especially to sesame and egg.

Diagnostic Decision Points of Specific IgE Concentrations in Korean Children With Egg and Cow's Milk Allergies

Purpose

The purpose of this study was to evaluate the utility of specific IgE (sIgE) concentrations for the diagnosis of immediate-type egg and cow's milk (CM) allergies in Korean children and to determine the optimal cutoff levels.

Methods

In this prospective study, children ≥12 months of age with suspected egg or CM allergy were enrolled. Food allergy was diagnosed by an open oral food challenge (OFC) or through the presence of a convincing history after ingestion of egg or CM. The cutoff levels of sIgE for egg white (EW) and CM were determined by analyzing the receiver operating characteristic curves.

Results

Out of 273 children, 52 (19.0%) were confirmed to have egg allergy. CM allergy was found in 52 (23.1%) of 225 children. The EW-sIgE concentration indicating a positive predictive value (PPV) of >90% was 28.1 kU/L in children <24 months of age and 22.9 kU/L in those ≥24 months of age. For CM-sIgE, the concentration of 31.4 kU/L in children <24 months of age and 10.1 kU/L in those ≥24 months of age indicated a >90% PPV. EW-sIgE levels of 3.45 kU/L presented a negative predictive value (NPV) of 93.6% in children <24 months of age, while 1.80 kU/L in those ≥24 months of age presented a NPV of 99.2%. The CM-sIgE levels of 0.59 kU/L in children <24 months of age and 0.94 kU/L in those ≥24 months of age showed NPVs of 100% and 96.9%.

Conclusions

Our results indicate that different diagnostic decision points (DDPs) of sIgE levels should be used for the diagnosis of egg or CM allergy in Korean children. The data also suggest that DDPs with high PPV and high NPV are useful for determining whether OFC is required in children with suspected egg or CM allergy.

Effect of heat treatment on milk and egg proteins allergenicity

BACKGROUND

Heating destroys many conformational epitopes and reduces allergenicity of some foods. IgE-epitope binding has been shown to be different among patients who outgrew their cow's milk or hen's egg allergy and those who did not. A significant proportion of milk- or egg-allergic children are tolerant to these foods in their baked forms. We sought to explore the effects of heating on milk and egg proteins and to evaluate for differences in immunolabeling among children with regard to reactivity to heated milk or egg.

METHODS

Sera from participants in clinical dietary intervention trials were utilized. Milk and egg samples were variably heated and prepared (at times within a wheat matrix). Sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis (PAGE), protein transfer, and Western blot were completed.

RESULTS

Sera from 20 milk-allergic and 24 egg-allergic children were utilized. Gel electrophoresis showed strongly staining casein bands that persisted for up to 60 min of heating. In contrast, β-lactoglobulin and α-lactalbumin bands became progressively weaker with increasing heating times, with no detectable β-lactoglobulin after 15-20 min of heating. The ovalbumin band became progressively weaker, whereas ovomucoid remained stable after 25 min of heating. Immunolabeling revealed that all heated milk-reactive children possessed IgE antibodies that bound the casein fraction regardless of heating time. Presence of wheat during heating resulted in decreased IgE antibody binding to milk and egg white proteins.

CONCLUSION

Heating has a different effect on whey and caseins in cow's milk and ovalbumin and ovomucoid in hen's egg white. The effect of heat on protein allergenicity is affected by the temperature and duration, along with the presence of wheat.

The role of casein-specific IgA and TGF-β in children with food protein-induced enterocolitis syndrome to milk

BACKGROUND

Food protein-induced enterocolitis syndrome (FPIES) is a gastrointestinal hypersensitivity disorder with a poorly understood pathophysiology and no biomarkers to aid in diagnosis.

OBJECTIVE

To investigate humoral and cellular responses to casein in children with milk-FPIES, including the role of casein-specific (cs) IgA and T-cell mediated TGF-β responses.

PATIENTS AND METHODS

Thirty-one children previously diagnosed with milk-FPIES were challenged with milk. Twelve age-matched children with FPIES to other foods and 6 milk-tolerant children without a history of FPIES were used as controls. Casein-specific IgE, IgG, IgG4, and IgA were measured in serum and TGF-β levels in supernatants of casein-stimulated PBMCs.

RESULT

Twenty-six children with milk-FPIES reacted (active milk-FPIES) and five tolerated milk (milk-FPIES resolved) during food challenge. All of them had significantly lower levels of csIgG, csIgG4, and csIgA than control children (p-value<0.001). There were no TGF-β responses in supernatants of active milk-FPIES children.

CONCLUSION

Children with milk-FPIES have low levels of csIgG, csIgG4, and csIgA. In particular, children with active FPIES to cow's milk have deficient T-cell mediated TGF-β responses to casein, rendering TGF-β a promising biomarker in identifying children who are likely to experience FPIES reactions to this allergen. Prospective studies are needed to validate these findings, elucidate their role in FPIES pathophysiology, and establish the diagnostic utility of TGF-β in milk-induced FPIES.