Current Trends in Tolerance Induction in Cow's Milk Allergy: From Passive to Proactive Strategies.

Cansin Sackesen,Zarife Kuloglu,Aysen Bingol,Derya Ufuk Altintas,Bulent Enis Sekerel,Aydan Kansu,Zeynep Tamay,Betul Buyuktiryaki,Gulbin Bingol,Esen Demir

doi:10.3389/fped.2019.00372

Cansin Sackesen, Zarife Kuloglu + Show 8 more

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https://doi.org/10.3389/fped.2019.00372

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This review addresses the current strategies of inducing tolerance development in infant and childhood cow's milk protein allergy (CMPA). The change in prevention strategies for CMPA has been emphasized based on the lack of evidence to support the efficacy of food allergen avoidance in infancy and the concept of the dual-allergen-exposure hypothesis, which suggests that allergen exposure through the skin leads to sensitization, whereas early oral consumption of allergenic food protein induces oral tolerance. The new approach is based on the likelihood of early introduction of allergenic foods to the infant's diet to reduce the development of food allergies through oral tolerance induction. The latest treatment guidelines recommend the continuation of breast feeding and the elimination of cow's milk and products from the maternal diet in exclusively breast-fed infants with CMPA, the use of an extensively hydrolyzed infant formula (eHF) with proven efficacy in CMPA as the first elimination diet in formula-fed infants with CMPA and the use of amino acid-based formula (AAF) in severe cases, such as anaphylaxis, enteropathy, eosinophilic esophagitis, and food protein-induced enterocolitis syndrome (FPIES), as well as cases of multiple system involvement, multiple food allergies, and intolerance to extensively hydrolyzed formula (eHF). In conclusion, this paper presents the current knowledge on tolerance development in infants and children with CMPA to increase the awareness of the clinicians concerning the new approaches in CMPA treatment Tolerance development is considered a relatively new concept in CMPA, inducing a shift in interventions in CMPA from a passive (avoidance of responsible allergen) toward a proactive (tolerance induction) strategy.

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There has been an alteration in the natural history of food allergy during the previous two decades with an increased prevalence, more severe clinical manifestations and higher risk of persistence into later ages [1,2,3,4].Given that oral exposure is considered to be responsible for allergic sensitization to food, an elimination diet has become the best strategy for the prevention of food allergies, and food allergen avoidance has been the mainstay preventive strategy in food allergy [4,5,6,7]
The intervention strategies in Cow’s milk protein allergy (CMPA) have been targeted at three levels: [1] primary prevention of initial IgE sensitization; [2] secondary prevention of the triggering of allergic reactions to interrupt the development of food allergy in IgE-sensitized children; and [3] tertiary prevention to reduce the manifestation of end-organ allergic disease in children with established food allergy via avoidance of allergenic food and induction of tolerance [6, 45]
This review by experts from Turkey aimed to document the current knowledge on tolerance development in infants and children with CMPA to increase the awareness of clinicians concerning the new approaches in CMPA treatment, given the change in the natural history and prevalence of food allergy during the last two decades and the related changes in the guidelines in terms of prevention and tolerance induction strategies in food allergies in recent years

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INTRODUCTION

There has been an alteration in the natural history of food allergy during the previous two decades with an increased prevalence, more severe clinical manifestations and higher risk of persistence into later ages [1,2,3,4]. The intervention strategies in CMPA have been targeted at three levels: [1] primary prevention of initial IgE sensitization; [2] secondary prevention of the triggering of allergic reactions to interrupt the development of food allergy in IgE-sensitized children; and [3] tertiary prevention to reduce the manifestation of end-organ allergic disease in children with established food allergy via avoidance of allergenic food and induction of tolerance (i.e., baked milk products, formulas, and oral immunotherapy) [6, 45]. An eHF or AAF might be necessary if breastfeeding is not an option or if blood in stools becomes severe (Table 2) [51]

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