What is milk protein allergy

A 800 g female preterm baby was born by vaginal delivery at 28 weeks to a 24-year-old gravid 2, para 1 mom. The neonate borned and she did not weep spontaneously. Apgar scores were 2/3/6 at 1/5/10 minutes. The baby was intubated in the delivery room and admitted to the neonatal intensive care unit. Trophic feeds were started on the fifth day of life with breast milk of mom. On the tenth day of life abdominal distension was developed. There is no signs of NEC on X-ray. Since the baby was clinically well we suspected cow’s milk-induced colitis and continued feeding with amino acid-based formula (Neocate).

After feeding with aminoacid-based formula clinical signs were delayed. The baby was discharged on aminoacidbased formula.

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Outcomes of oral tolerance induction in cow´s milk protein allergy

Introduction: Cow´s milk protein allergy (CMPA) is the most common food allergy.

It affects5% of children in early childhood and in 20% of these, may persist during the second decade of life. In subjects with persistent allergy, accidents with hidden allergens may happen, mainly in adolescents, because of the poor control in their diet. As such, these adolescents and family members show a significant anxiety and a reduction in their quality of life. Cow´s milk oral tolerance induction (OTI) is an innovative treatment option for persistent IgE-mediated CMPAapproach.

Objectives:To assess the outcome and safety of OTI to cow’s milk protein (CMP) protocol, in children with persistent CMPA, IgE-mediated, attending the Paediatric Allergology Department in Paediatric Hospital of Coimbra.

Material and Methods: in the final 25 months (March 2012 to April 2014) 10 children were included in the OTI to CMP protocol.

Every of them had persistent IgE-mediated CMPA, with symptoms beginning in the first year of life and allergic manifestations in the 12 months before starting the OTI. The ongoing protocol uses pure CM as allergen, starting with sublingual doses followed by oral ingestion of increasing doses, always in inpatient regimen until the target dose of 200ml per day is achieved.

Conclusion: The protocol used has proved to be effective, simple and relatively safe.

What is milk protein allergy

Most patients reached a dose that allows a more free diet, with obvious improvement in the quality of life. However the failure rate is still high, 20% in our case series(2/10). We believe this treatment should be offered to every patients with persistent IgE-mediated CMPA.

TY — JOUR

T1 — Diagnostic approach and management of cow’s milk protein allergy in infants and children

T2 — A practical guideline of the GI-committee of ESPGHAN

AU — Koletzko, S

AU — Niggemann, B

AU — Arato, A

AU — Dias, J A

AU — Heuschkel, R

AU — Husby, S

AU — Mearin, M L

AU — Papadopoulou, Aikaterini

AU — Ruemmele, F M

AU — Staiano, A

AU — Schäppi, M G

AU — Vandenplas, Y

PY — 2012

Y1 — 2012

N2 — OBJECTIVES:: This position paper provides recommendations for the diagnosis and management of suspected cow’s milk protein allergy (CMPA) in Europe.

It presents a practical approach with a diagnostic algorithm and is based on recently published evidence based guidelines on CMPA. DIAGNOSIS:: If CMPA is suspected by history and examination, strict allergen avoidance is initiated. In certain circumstances (e.g. a clear history of immediate symptoms or a life threatening reaction with a positive test for cow’s milk protein (CMP) specific IgE) the diagnosis can be made without a milk challenge. In every other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis CMPA.

TREATMENT:: In breast-fed infants, the mom should start a strict CMP-free diet. Non-breast fed infants with confirmed CMPA should get an extensively hydrolyzed protein based formula with proven efficacy in appropriate clinical trials; amino acids based formulae are reserved for certain situations.

What is milk protein allergy

Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth is mandatory in every age groups requiring CMP exclusion. RE-EVALUATION:: Patients should be re-evaluated every 6-12 months to assess whether they own developed tolerance to CMP. This is achieved in >75% by three years and >90% by six years of age. Inappropriate or overly endless dietary eliminations should be avoided.

Such restrictions may impair the quality of life of both kid and family, induce improper growth, and also incur unnecessary healthcare costs.

AB — OBJECTIVES:: This position paper provides recommendations for the diagnosis and management of suspected cow’s milk protein allergy (CMPA) in Europe. It presents a practical approach with a diagnostic algorithm and is based on recently published evidence based guidelines on CMPA. DIAGNOSIS:: If CMPA is suspected by history and examination, strict allergen avoidance is initiated. In certain circumstances (e.g.

a clear history of immediate symptoms or a life threatening reaction with a positive test for cow’s milk protein (CMP) specific IgE) the diagnosis can be made without a milk challenge. In every other circumstances, a controlled oral food challenge (open or blind) under medical supervision is required to confirm or exclude the diagnosis CMPA. TREATMENT:: In breast-fed infants, the mom should start a strict CMP-free diet. Non-breast fed infants with confirmed CMPA should get an extensively hydrolyzed protein based formula with proven efficacy in appropriate clinical trials; amino acids based formulae are reserved for certain situations.

Soy protein formula, if tolerated, is an option beyond 6 months of age. Nutritional counseling and regular monitoring of growth is mandatory in every age groups requiring CMP exclusion. RE-EVALUATION:: Patients should be re-evaluated every 6-12 months to assess whether they own developed tolerance to CMP. This is achieved in >75% by three years and >90% by six years of age. Inappropriate or overly endless dietary eliminations should be avoided.

Such restrictions may impair the quality of life of both kid and family, induce improper growth, and also incur unnecessary healthcare costs.

U2 — 10.1097/MPG.0b013e31825c9482

DO — 10.1097/MPG.0b013e31825c9482

M3 — Journal article

C2 — 22569527

VL — 55

SP — 221

EP — 229

JO — Journal of Pediatric Gastroenterology and Nutrition

JF — Journal of Pediatric Gastroenterology and Nutrition

SN — 0277-2116

IS — 2

ER —

There is no specific test to detect cow’s milk allergy. The basis of diagnosis is primarily on the history of symptoms and physical exam.

It is significant to detail the timeline of symptoms and when they happen. Carrying out a diagnostic protocol in infants for suspected cow’s milk allergy may assist to law in or out the disease.[11]

Primary tests, if used, include a skin prick test and serum specific IgE. Both tests show high sensitivity but low specificity and can be positive in non-allergic subjects.[12]

Serum specific IgE to cow’s milk allergy: Can aid in the diagnosis of IgE mediated cow’s milk allergy and cut off values are multifactorial and should be set by each allergist.[13]

Skin prick test: Is performable by an allergy specialist. 

Diet elimination: If suspected, an baby should get a diet free of cow’s milk protein for a month.

If symptoms improve following elimination of the suspected food, then an oral food challenge is the gold standard test.[14] This challenge must be in a medical setting due to concern for systemic IgE mediated reaction.

What is milk protein allergy

Patients should undergo reevaluation every 6 to 12 months to determine if they own developed a tolerance to cow’s milk protein.[15]

Algorithm:

1: If there are signs of anaphylaxis or immediate reaction, then diet elimination is recommended, and testing for serum IgE should follow. If serum specific IgE is positive, then the kid is diagnosed with a cow’s milk allergy. If IgE is negative and symptoms improve after diet elimination, an oral challenge should be next. If the symptoms reoccur, the diagnosis is confirmed.

What is milk protein allergy

If the symptoms do not reoccur, then the diagnosis of cow’s milk allergy is excluded.[9]

2: If the symptoms are not consistent with anaphylaxis or immediate reaction, then an elimination diet is recommended. If symptoms improve, then an oral challenge should be done, and if symptoms reoccur, the diagnosis is confirmed. If the symptoms do not reoccur, it excludes the diagnosis of cow’s milk allergy.[16][9]

3: If symptoms do not improve after the elimination diet, this eliminates the diagnosis of cow’s milk allergy, and further evaluation should be done to assess the patient.[9]

Cow`s milk protein allergy is not a minor ailment, it is a serious disease.

If untreated early and properly, it can pave the way for other serious illnesses, experts argued during a debate in Warsaw.

The theme of the debate was: «Milk allergy — a transient problem of infancy or a harbinger of further diseases». The data presented during the discussion show that food allergies happen in 9-10% children. One of the most common food allergens is cow`s milk protein, to which 3% newborns and babies are allergic.

National paediatric gastroenterology consultant Prof. Mieczysława Czerwionka-Szaflarska warned against underestimating child`s food allergies, especially the cow`s milk protein allergy.

«It`s not just a minor ailment, it is a serious disease» — she emphasized.

What is milk protein allergy

Along with other experts, she warned that if the allergy is not sufficiently early and properly treated, at a later age of the kid it may also pave the way for other allergic diseases, such as atopic dermatitis, bronchial asthma and allergic rhinitis. This especially applies to IgE-mediated allergy, which consists in the immune system producing IgE antibodies specific for cow`s milk proteins.

Allergy to cow`s milk protein generally has a mild, moderate form — explained Prof.

Piotr Albrecht, head of Department of Pediatric Gastroenterology and Nutrition of the Medical University of Warsaw. «In 90 percent children, food allergy generally disappears in the period from 2 to 4 years of age. However, if it is poorly treated, it threatens the development of the so-called allergic march, that is, the emergence of other allergic diseases» — he stressed.

Experts emphasized the importance of early detection of food allergy.

Its symptoms may include eczema and skin rashes, diarrhoea, vomiting, constipation and gastro-oesophageal reflux, as well as respiratory ailments manifested by wheezing, coughing or sneezing, difficulty breathing, runny nose and swelling of the nose. «Children affected by this type of allergies sometimes scratch every day, sleep badly and become nervous» — emphasized Prof.

What is milk protein allergy

Albrecht. Some babies do not own serious symptoms, they only refuse to take food.

Cow`s milk protein allergy, especially in its mild and moderate form, can be diagnosed by a primary care physician. «A primary care physician can also prescribe allergy preparations that are refunded from the budget» — said Prof. Czerwionka-Szaflarska. The istration of such preparations, instead of the elimination diet, hard to implement in the case of cow`s milk protein, allows to avoid nutritional deficiencies.

The expert emphasised that when a kid receives milk for allergy sufferers, it should not be referred to a specialist, for example an allergist, because the specialist will not be capable to diagnose anything.

In any case, only children with severe food allergies, which in extreme cases may even lead to anaphylactic shock (life-threatening significant reduction in blood pressure), should be referred to specialists.

Head of the Chair and Clinic of Allergology and Clinical Immunology and Internal Diseases of the Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz Prof. Zbigniew Bartuzi noted that in some cases cow`s milk protein allergy may not be related to IgE antibodies. It causes similar symptoms, such as diarrhoea, flatulence, intestinal discomfort, but they generally appear later (from 1 hour to a few days after exposure to cow`s milk protein).

The specialist warned that one should not use so-called alternative allergy tests, such as iridology and hair testing, to detect allergies.

«They are not dependable and do not permit to make the correct diagnosis» — he stressed. He added that if they were useful, allergists would be using them. Doctors use so-called spot tests to check individual substances that may be sensitising.

Food allergy is also confused with food intolerance, caused by deficiency or lack of enzymes necessary for the proper digestion of nutrients. In the case of cow`s milk, some people lack the enzyme (lactase) or it is not fully functional in the breakdown of lactose (disaccharide in the milk of mammals).

According to Prof.

Bartuzi, 30-35 percent Poles are cow`s milk intolerant, and some symptoms, such as stomach aches, bloating and diarrhoea in the form of foamy stools, may be similar to cow`s milk protein allergy. He noted that the age, at which cow`s milk tolerance appears, has been moved. In the 1990s, in 75 percent people it developed at the age of 5, and now on average at around 16 years of age. However, in an increasing number of people, it develops only during adulthood, or does not develop at all» — he explained.

Allergies are becoming more and more common.

According to the World Allergy Organization (WAO), 30-40 percent world population has at least one allergic disease, especially in the most industrialized countries. The Polish Allergy Society estimates that almost half of Poles are affected by allergies.

PAP — Science in Poland, Zbigniew Wojtasiński

zbw/ ekr/ kap/

tr. RL


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