Amino Acid-based Formula Research Articles

Regional differences in diagnosis and management of cow's milk allergy.

: Various guidelines for the diagnosis and management of cow's milk allergy (CMA) have been pu- blished. : This study aimed to compare voting outcomes of experts from Mexico, the Middle East, and the European Society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) on statements regarding CMA. : The 3 expert groups voted on the same 10 state- ments. Each participant voted anonymously using a score of 0-9 (≥6 meant agreement; <5 reflected disagreement). If <75% of the participants agreed with the statement, it was rejected. None of the groups was aware of the voting outcomes of another group. : There was broad consensus amongst the 3 groups. Agreement was reached that infant colic as a sin- gle manifestation is not suggestive of CMA. All groups confirmed that an extensively hydrolysed formula is the preferred elimination diet in mild/moderate CMA cases; however, hydrolysed rice formula is an alternative. Amino acid-based formulas should be reserved for infants with severe symptoms. The discrepancy in voting outcomes re- garding soy formulas highlights the differences in opinions. Two of 13 ESPGHAN experts (15%), 1 of 14 Middle East experts (7%), and 6 of 26 Mexican experts (23%) disagreed with the statement that soy formula should not be the first choice for the diagnostic elimination diet but can be considered in some cases for economic, cultural, and pala- tability reasons. All of the ESPGHAN and Mexican ex- perts agreed that there was no added value of probiotics, prebiotics, or synbiotics to the efficacy of elimination diets on CMA, whereas 3 of 14 Middle East experts (21%) deter- mined that there was sufficient evidence. : Although all statements were accepted by the 3 groups, there were relevant differences illustrating va- riations according to geography, culture, cost, and formula availability. These findings emphasize the need for region-specific guidelines.

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update – XVI - Nutritional management of cow's milk allergy

Cow's milk allergy (CMA) is one of the most common presentations of food allergy in early childhood. Management of CMA involves individualized avoidance of cow's milk and other mammalian milk and foods containing these. Optimal elimination of cow's milk avoidance includes: label reading; information about safe and nutritious substitute foods; appropriate choice of infant formula or a plant-based food; establishing tolerance to baked milk and monitoring nutritional intake and growth. Substitute formulas are divided into soy formula (not hydrolyzed), milk-based extensively hydrolyzed formulas, rice based extensive, and partially hydrolyzed formulas and amino acid-based formulas. The use of other mammalian milks is not recommended for the management of cow's milk allergy due to a high level of cross-reactivity and nutritional concerns. For toddlers who are eating well, children, and adults, a suitable plant-based beverage may be a suitable alternative to a specialized formula, following careful nutritional considerations. Families need to be instructed on finding suitable nutritious foods and how to prepare suitable meals at home. Individuals with CMA also need to know how to identify and treat acute severe reactions.

Gut microbiota in infants with food protein enterocolitis.

We explored the effects of two formulas, extensively hydrolyzed formula (EHF) and amino acid-based formula (AAF), on the gut microbiota and short-chain fatty acids (SCFAs) in infants with food protein-induced enterocolitis syndrome (FPIES). Fecal samples of thirty infants with bloody diarrhea receiving EHF or AAF feeding were collected at enrollment, diagnosis of FPIES, and four weeks after diagnosis. The gut microbiota and SCFAs were analyzed using 16 S rRNA gene sequencing and gas chromatography-mass spectrometry, respectively. Microbial diversity of FPIES infants was significantly different from that of the controls. FPIES infants had a significantly lower abundance of Bifidobacterium and a higher level of hexanoic acid compared with controls. In EHF-fed FPIES infants, microbial richness was significantly decreased over time; while the microbial diversity and richness in AAF-fed FPIES infants exhibited no differences at the three time points. By four weeks after diagnosis, EHF-fed FPIES infants contained a decreased abundance of Acinetobacter, whereas AAF-fed FPIES infants contained an increased abundance of Escherichia-Shigella. EHF-fed infants experienced significantly decreased levels of butyric acid and hexanoic acid at four weeks after diagnosis. Infants with FPIES had intestinal dysbiosis and different formulas differentially affected gut microbiota and SCFAs in FPIES infants. We firstly report the impacts of two different nutritional milk formulas on the gut microbial composition and SCFAs levels in infants with FPIES. We show that infants with FPIES have obvious intestinal dysbiosis and different formulas differentially affect gut microbiota and SCFAs in FPIES infants. Understanding the effects of different types of formulas on gut microbial colonization and composition, as well as the related metabolites in infants with FPIES could help provide valuable insights for making choices about feeding practices.

Growth in healthy infants with cow's milk protein allergy fed extensively hydrolyzed or amino acid-based formulas

BackgroundCow’s milk protein allergy (CMPA) is one of the most common food allergies in the first year of life. Special formulas for infants with CMPA include extensively hydrolyzed (EHFs) and amino acid-based (AAFs) formulas. The aim of this study was to evaluate the growth of infants fed with these special formulas.MethodsThis was a prospective chart review study that evaluated the growth criteria of infants with CMPA fed with EHFs or AAFs until one year of age. These infants were referred to the gastroenterology clinic of Bahrami Children's Hospital from April 2021 to April 2022. These infants were divided into two groups, the group fed with EHFs and AAFs. Then growth criteria were evaluated in both groups.ResultsFifty-eight children were enrolled in the study, of which 51.7% were girls. Forty were consuming the EHFs formulas. The median time of both diagnosis and treatment was 60 days. The most common clinical manifestations were gastroesophageal reflux, dysentery, eczema, vomiting, and cough, respectively. The diagnosis of the disease in the AAFs group was significantly earlier than in the other group. The growth of children in both groups was completely proportional to their age and growth criteria at birth. Comparing the groups, all growth parameters were higher in the EHFs group.ConclusionThis study showed that the growth criteria (weight, length, and head circumference) were suitable for each group and were in accordance with the WHO growth charts compared to the birth criteria. But in the group fed with EHFs, compared to AAFs, the growth rate was higher.

Symptoms and management of cow's milk allergy: perception and evidence.

The diagnosis and management of cow's milk allergy (CMA) is a topic of debate and controversy. Our aim was to compare the opinions of expert groups from the Middle East (n = 14) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (n = 13). These Expert groups voted on statements that were developed by the ESPGHAN group and published in a recent position paper. The voting outcome was compared. Overall, there was consensus amongst both groups of experts. Experts agreed that symptoms of crying, irritability and colic, as single manifestation, are not suggestive of CMA. They agreed that amino-acid based formula (AAF) should be reserved for severe cases (e.g., malnutrition and anaphylaxis) and that there is insufficient evidence to recommend a step-down approach. There was no unanimous consensus on the statement that a cow's milk based extensively hydrolysed formula (eHF) should be the first choice as a diagnostic elimination diet in mild/moderate cases. Although the statements regarding the role for hydrolysed rice formula as a diagnostic and therapeutic elimination diet were accepted, 3/27 disagreed. The votes regarding soy formula highlight the differences in opinion in the role of soy protein in CMA dietary treatment. Generally, soy-based formula is seldom available in the Middle-East region. All ESPGHAN experts agreed that there is insufficient evidence that the addition of probiotics, prebiotics and synbiotics increase the efficacy of elimination diets regarding CMA symptoms (despite other benefits such as decrease of infections and antibiotic intake), whereas 3/14 of the Middle East group thought there was sufficient evidence. Differences in voting are related to geographical, cultural and other conditions, such as cost and availability. This emphasizes the need to develop region-specific guidelines considering social and cultural conditions, and to perform further research in this area.

Evaluation of Deficient Nutrients in Infants and Toddlers Mainly Taking Amino Acid-Based Elemental Formulas: An Exploratory Study

Introduction: This study evaluated nutrient deficiencies in infants and toddlers with inflammatory bowel disease (IBD) and eosinophilic gastrointestinal disorders (EGIDs), whose primary nutritional source is elemental formulas (EFs). Methods: The nutrient status of children with IBD and EGID aged 6 months to 6 years was evaluated. Results: Twenty-one children fed with EFs (EF group) and 25 controls (CL group) were enrolled. The selenium level in the EF group was lower than that in the CL group (2.2 μg/dL vs. 9.3 μg/dL; p < 0.01). Although fat-soluble vitamins were deficient in some EF group participants, no significant differences were observed in their concentration and insufficiency proportion. However, ascorbic acid deficiency was more frequent in the EF group, with significantly lower levels (8.6 μg/mL vs. 12.0 μg/mL; p < 0.01). The triene:tetraene ratio was significantly higher in the EF group (0.046 vs. 0.010; p < 0.01). Asparagine and taurine levels were significantly lower in the EF group (asparagine: p < 0.01; taurine: p < 0.01) and tyrosine and phenylalanine levels were higher in the EF group, resulting in a lower Fisher’s ratio (p < 0.01). Conclusion: Long-term feeding with EFs can cause deficiencies in essential fatty acids, selenium, and ascorbic acid and also carries a risk of amino acid imbalance in infants and toddlers.

Evaluation of Streptococcus mutans Biofilm Formation and Acidogenicity of Infant Milk Formulas for Treating Cow Milk Allergy: An in vitro Study

Introduction: When infants cannot consume breast milk, the most commonly available alternative milk formula is cow milk-based. Due to a rise in the prevalence of cow milk protein allergy (CMPA) among children, this study aimed to assess the biofilm formation and acidogenicity of cow milk-based formulas as well as milk formulas suggested for children with CMPA. Methods: Cow milk-based formulas with 0%, 10%, or 18% sucrose added, partially hydrolyzed formula (pHF), extensively hydrolyzed formula (eHF), amino acid-based formula (AAF), and soy-based formulas with 0%, or 11% sucrose added were evaluated. Streptococcus mutans was used as a representative microorganism associated with caries. The acidogenicity after 24-h incubation was assessed by the pH of the formed biofilm and lactic acid formation. Biofilm formation was quantified using crystal violet staining. Additionally, the biofilm characteristics were determined using confocal laser scanning microscopy (CLSM). Comparisons were made among formulas without added sucrose to observe protein-based differences. Furthermore, formulas with different sucrose percentages were compared to explore the impact of sucrose content. Results: When comparing the formulas without added sucrose, the biofilm formation in the cow milk-based formula and pHF were significantly greater than the soy-based formula, eHF, and AAF. In the presence of S. mutans, all formulas reduced the biofilm pH below the critical enamel pH. The cow milk-based formula and AAF showed a significantly lower biofilm pH than the pHF, soy-based, and eHF groups, while the lactic acid production was markedly higher in the cow milk-based formula, pHF and AAF, compared with the eHF and soy-based formula. Adding sucrose into the cow milk-based and soy-based formulas substantially increased biofilm mass. The biofilm pH of the cow milk-based formulas, with or without sucrose, was significantly lower than that of the soy-based formulas. The CLSM indicated distinct biofilm characteristics among the different protein-based formulas, with sucrose supplementation promoting S. mutans aggregation in cow milk-based formula biofilm and increased density and intact biofilm in the soy-based formula. Conclusion: All assessed milk formulas had caries-inducing factors, including those without supplemental sucrose. Among them, the eHF demonstrated the least caries-inducing factors, attributed to its minimal biofilm formation and the highest biofilm pH.

Gastrointestinal Tolerance and Acceptance of An Amino Acid-Based Formula with An Alternative Carbohydrate Sourced from Tapioca

Gastrointestinal Tolerance and Acceptance of An Amino Acid-Based Formula with An Alternative Carbohydrate Sourced from Tapioca

Amino acid-based enteral nutrition is effective for pediatric Crohn's disease: a multicenter prospective study.

Exclusive enteral nutrition (EEN) therapy effectively induces remission in pediatric Crohn's disease (CD). However, this may depend on the type of enteral formula used. Moreover, data on the efficacy of amino acid-based EEN are limited. Thus, we aimed to prospectively evaluate the efficacy of amino acid-based formulas for EEN in pediatric patients with active CD. Patients with active CD aged between 6 and 17 years were recruited into this prospective study from four hospitals in China between March 2019 and December 2021. Patients received EEN for 8 weeks. Inflammatory and nutrition-associated indices were evaluated at 0, 4, and 8 weeks after treatment. Paired t-tests and Wilcoxon signed-rank tests were used to compare continuous and categorical variables before and after intervention, respectively. Twenty-four patients were included in the analysis. After an 8-week intervention period, the CD activity index significantly decreased (26.3 ± 12.2 vs 7.1 ± 8.3, P < 0.001). Most patients (66.7%) achieved complete clinical remission. Among the 22 patients who had ulcers and erosions diagnosed endoscopically at baseline, 10 (45.5%) achieved complete mucosal healing. The degree of thickening of the intestinal wall was significantly reduced after EEN intervention, with a transmural healing rate of 42.9%. Furthermore, the serum inflammatory markers decreased and there was a significant improvement in the nutrition-related indices (P < 0.05). There were no severe adverse effects. Amino acid-based EEN is effective and safe for treating pediatric-onset CD. Studies with larger sample sizes and mechanistic and follow-up studies are required to further validate these findings.

Soy Formula as An Alternative for Infants with Cow’s Milk Allergy: Perspective from Pediatricians and Midwives in Indonesia

The prevalence of food allergy in children is increasing globally, with cow's milk allergy beingthe most common in infants and increasing from 2% to 3% in developed countries. However, data oncow's milk allergy in infants is limited in Indonesia. This study used a mixed methods approach using anonline survey and in-depth interviews. The survey was conducted from September 2021 to March 2022.Qualitative analysis, all interviews were recorded and transcribed. Data were analyzed using simplethematic analysis. The results showed that a total of 93 pediatricians and 104 midwives participated inthe survey. However, among the 93 pediatricians, only 56 (60.2%) completed the survey. Meanwhile, 11midwives (10.6%) were excluded because they had no experience in handling CMA cases. The majorityof CMA cases occurred in children under two years old, and most were treated by pediatricians. In termsof diagnostic tests, 51.8% of pediatricians recommended all specific IgE tests, prick tests, and provocationtests to diagnose allergies. More than 80% (46/56) of pediatricians chose to avoid all types of cow's milkproducts in the mother and child's diet as the main treatment. Meanwhile, only 22.1% of midwives didthe same. Milk choice will differ depending on the severity of CMA. Soy milk formula is preferred bymidwives for patients with low-level and moderate to severe allergies. Meanwhile, pediatriciansrecommend extensive hydrolysate formula for low severity patients and amino acid-based formula formoderate to severe.

Outcomes and factors associated with tolerance in infants with non-IgE-mediated cow's milk allergy with gastrointestinal manifestations

ObjectivesTo evaluate outcomes of oral food challenge (OFC) test to assess tolerance in infants with non-IgE-mediated cow's milk allergy (CMA) with gastrointestinal manifestations and explore clinical data predictive of these outcomes. MethodsSingle-center retrospective study including infants (age < 12 months) who were referred for CMA between 2000 and 2018 and underwent OFC on follow-up. A univariate logistic regression test was performed to evaluate variables associated with the outcomes of the follow-up OFC test. ResultsEighty-two patients were included, 50% were male. Eighteen patients had a positive OFC test (22%). Most patients had presented with hematochezia (77%). The median age of symptom onset was 30 days. Two-thirds of the patients were on appropriate infant formula (extensively hydrolyzed or amino acid-based formula), exclusively or in association with breastfeeding. The median time on an elimination diet before the OFC test was 8 months (Q1 6 – Q3 11 months). All cases with positive follow-up OFC tests (n = 18) had been exposed to cow's milk-based formula before the first clinical manifestation of CMA. Five out of eight cases with Food Protein-Induced Enterocolitis Syndrome (FPIES) had positive OFC tests. Exposure to cow's milk-based formula before diagnosis, a history of other food allergies, hematochezia and diarrhea were predictors of a positive OFC test. ConclusionsIn infants with non-IgE-mediated CMPA with gastrointestinal manifestations, the use of cow's milk-based formula, a history of other food allergies, and hematochezia and diarrhea upon initial presentation were associated factors for the later achievement of tolerance.

Trackability of proteins from probiotic Bifidobacterium spp. in the gut using metaproteomics.

Beneficial effects of Bifidobacterium spp. on gut microbiota development and infant health have been reported earlier. Therefore, supplementation of infant formulas with probiotic bifidobacteria, as well as prebiotics stimulating bifidobacterial growth, has been proposed. Here, we studied the faecal microbiome of infants supplemented with specialized nutrition, of which some received a standard amino acid-based formula (AAF) and others an AAF with a specific mixture of prebiotics and a probiotic (synbiotics) using metaproteomics and 16S rRNA gene sequencing. Faecal samples were taken at baseline, as well as after 6 and 12 months fed with the specialized formula. The aim was to compare microbial differences between infants treated with the standard AAF and those who received the additional synbiotics. Our findings show that infants who received AAF with synbiotics have significantly higher levels of Bifidobacteriaceae DNA as well as significantly increased levels of Coriobacteriaceae proteins, over time. Moreover, at visit 12 months higher levels of some bifidobacterial carbohydrate-active enzymes, known to metabolize oligosaccharides, were observed in the synbiotic group compared to the non-synbiotic group. The results indicate that the synbiotics provided in our study are trackable in faecal samples on the DNA and protein level during the intervention period.

Spanish Pediatricians' Positions Regarding Prevention, Diagnosis, Nutritional Management, and Challenges in Cow's Milk Protein Allergy.

Management of cow's milk protein allergy (CMPA) can vary depending on the experience and area of expertise of the clinician responsible for the patient's follow-up, which may or may not align with the recently published literature. To analyze the perspectives of Spanish pediatricians on this topic, a survey was conducted. The survey aimed to determine the current opinions and attitudes of 222 primary care and hospital pediatricians toward CMPA prevention and nutritional management. Participating pediatricians completed the questionnaire, providing insights into their daily clinical practices, including access to testing, attitudes with respect to various aspects of CMPA diagnosis, prevention, oral food challenges, and treatment. The findings revealed that pediatricians generally agree on the use of extensively hydrolyzed formulas (eHFs) to prevent CMPA in high-risk atopic children, despite limited evidence supporting the widespread use of this practice. However, consensus was lacking regarding the utility of formulas with prebiotics and probiotics for expediting tolerance development. In most cases, pediatricians preferred eHFs for the nutritional management of CMPA, followed by hydrolyzed rice formulas (HRFs), with amino-acid-based formulas (AAFs) being the third option. Certain issues remained controversial among pediatricians, such as prevention methods, symptom assessment, and the role of probiotics. These variations in management approaches reflect the influence of clinician experience and area of expertise, underscoring the need for standardized guidelines in this field.

Effects of a new amino acid, rice glucose polymer-based, and commercial amino acid-based formulas on growth and protein status of infants with cow's milk protein allergy.

Infants with cow's milk protein allergy (CMPA) are at risk for nutrient inadequacy and impaired growth. To evaluate the effect of a new amino acid-based formula (nAAF) compared with commercial amino acid-based formula (cAAF) on growth and protein status of cow's milk protein (CMP)-allergic infants and to compare their growth with those of healthy infants. Infants less than 6 months of age with CMPA were enrolled in the nAAF or cAAF groups. Healthy infants fed breast milk (BM) or infant formula (IF) were controls. They remained on their formula/milk until day 28 of the study. Anthropometric evaluation was performed at birth, day 0 and day 28 of the study and calculated to z-scores of weight-for-age (WAZ), length-for-age (LAZ) and head circumference-for-age (HAZ). Plasma amino acids, albumin, urea nitrogen, and creatinine were assessed for infants with CMPA on day 0 and day 28. The nAAF and cAAF groups did not differ in increases in WAZ [regression coefficient (95%CI): 0.088 (-0.619, 0.796), p = 0.791], LAZ [0.045 (-0.789, 0.880, p = 0.909], and HAZ [-0.645 (-2.082, 0.793), p = 0.337] between day 0 and day 28. The increases in WAZ and LAZ during 28 days in the nAAF group did not differ from the controls. The changes in the blood chemistry values, except albumin, were not different between CMPA groups. The nAAF, similar to the cAAF, supports growth and protein status for infants with CMPA, and it might be used as a substitute for the cAAF.

The use of amino acid formulas in pediatric patients with allergy to cow's milk proteins: Recommendations from a group of experts.

One of the most common food allergies in children is cow's milk allergy (CMA). In breast-fed infants with CMA, the mother is encouraged to avoid dairy products. If this is not possible, or in formula fed infants, use of hypoallergenic replacement formulas such as extensively hydrolyzed formulas (EHF) is recommended. However, in ∼5% of patients EHFs are not tolerated and/or allergy symptoms can persist. When EHFs are ineffective and in severe forms of CMA, amino acid-based formulas (AAF) should be considered. Six pediatric gastroenterologists with extensive experience in food allergy management reviewed scientific publications and international clinical practice guidelines to provide practical recommendations on AAF. The guidelines reviewed had discrepancies and ambiguities around the specific indications for using formulas as a milk substitute. The panel recommends AAFs as the first therapeutic option in anaphylaxis due to CMA, in acute and chronic severe food protein-induced enterocolitis syndrome, in CMA associated with multiple food allergy, and in cases of eosinophilic esophagitis not responding to an extended exclusion diet or not eating solids. The main benefit of AAF is its absence of residual allergenicity, making it a safe treatment option in severe CMA patients who do not tolerate or respond to an EHF.

Real-life data on the effectiveness of extensively hydrolyzed protein-based formula and amino acid-based formula in regaining weight and height in infants on a cow's milk protein elimination diet.

To compare the effectiveness of extensively hydrolyzed protein-based formula (EHF) or amino acid-based formula (AAF) in reversing the weight and height deficit in infants on a cow's milk protein elimination diet. Infants from a retrospective cohort who were fed EHF (n = 17) or AAF (n = 16) for at least 2 months on a cow's milk protein elimination diet were included. The weight and height values recorded in the infants' medical records were obtained. The mean age of the infants at the start of EHF and AAF were 5.8 ± 2.6 and 4.4 ± 2.5 months, respectively (P = 0.061). There was no difference between the groups in terms of the monthly weight gain (373.0 ± 212.2 and 453.1 ± 138.5 g, P = 0.223, respectively, for EHF and AAF), while the monthly increase in height was greater in the group fed with AAF (1.3 ± 0.5 and 1.8 ± 0.6, P = 0.030). A comparison between the difference in the initial z-score and in the oral challenge test of weight-for-age (+0.7 ± 1.2 and +1.3 ± 1.4, P = 0.262, respectively, for the EHF and AAF groups), height-for-age (+0.2 ± 1.1 and +1.2 ± 1.8, P = 0.090), and body mass index (BMI)-for-age (+0.7 ± 1.3 and +0.7 ± 1.5, P = 0.971) did not reveal a statistically significant difference between the groups. Correlation coefficients showed that the greater the initial nutritional deficit, the greater the positive variation between the beginning of each formula and the oral challenge test. EHF and AAF provided similar increases in the weight-for-age, height-for-age, and BMI-for-age z-scores in both groups. The monthly increase in height was greater in infants who received AAF.

Congenital syphilis in a preterm newborn with gastrointestinal disorders and postnatal growth restriction

BackgroundCongenital syphilis (CS) depends on the placental transmission of Treponema pallidum (TP) spirochetes from an infected mother to fetus during pregnancy. It shows a wide clinical variability with cutaneous and visceral manifestations, including stillbirths, neonatal death, and asymptomatic cases. Preterm infants with CS may have more severe features of disease than the term ones, due to the combined pathogenic effect of both CS and prematurity.Case presentationWe report on a female preterm (32+6 weeks of gestation) newborn showing most of the typical CS manifestations, in addition to gastrointestinal disorders including feeding difficulties, colon stenosis and malabsorption leading to postnatal growth restriction. The mother resulted positive at the syphilis screening test of the first trimester of pregnancy, but she did not undergo any treatment. At birth, our newborn was VDRL positive (antibody titer four times higher compared to the mother), and she was treated with intravenous benzathine benzylpenicillin G for 10 days (50,000 IU/Kg three times per day). Poor tolerance to enteral nutrition (abdominal distension, increased biliary type gastric secretions) was observed. A barium enema X-Ray identified a colon stenosis within the descending tract. However, the poor general conditions due to a concurrent fungal sepsis did not allow to perform any surgical procedure, and a conservative approach with total parenteral nutrition was started. The following evolution was marked by difficulties in enteral feeding including refusal of food and vomiting, to which also contributed the neurological abnormalities related to a perinatal asphyxia, and the affective deprivation for the physical absence of the mother during hospitalization. At 5 months of age, after the introduction of an amino acid-based formula (Neocate LCP Nutricia ®), an improvement of enteral feeding was observed, with no further and significantly decreased episodes of abdominal distension and vomiting respectively, and regular stool emission. A psychological support offered to the family allowed a more stable bond between the mother and her baby, thus providing a significant additional benefit to food tolerance and growth. She was discharged at 5 months of age, and included in a multidisciplinary follow-up. She at present shows global growth delay, and normal development apart from mildly increased tone of lower limbs.ConclusionsOur report highlights less common clinical CS manifestations like gastrointestinal disorders including feeding difficulties, colon stenosis and malabsorption leading to postnatal growth delay. Moreover, it underlines how prematurity may worsen the clinical evolution of such congenital infection, due to the additional pathogenic effect of possible associated diseases and/or conditions like sepsis, hypoxic/ischemic injury, or use of drugs. CS may be observed also in high-income countries, with high rates of antenatal screening and availability of prenatal treatment. A multidisciplinary network must be guaranteed to the affected subjects, to ensure adequate care and improve the quality of life for patients and their families.

Cost-effectiveness of infant hypoallergenic formulas to manage cow’s milk protein allergy in France

ABSTRACT Background Clinician’s choice of hypoallergenic formulas in the first-line management of cow’s milk protein allergy (CMPA) should be informed by evidence on clinical efficacy and cost-effectiveness. Objective We compare the cost-effectiveness of amino acid-based formula (AAF), extensively hydrolyzed casein formula with Lactobacillus rhamnosus Gorbach Goldin (EHCF+LGG), extensively hydrolyzed whey formula (EHWF), and rice hydrolyzed formula (RHF) in non-breastfed children in France. Methods Immunotolerance and atopic manifestations’ prevalence were based on a prospective non-randomized study with a 36-month follow-up. Resource utilization was sourced from a survey of French clinicians, and unit costs were based on national data. Costs and health consequences were discounted at 2.5% annually. Results were reported using the Collective and French National Health Insurance perspectives. Results Children receiving EHCF+LGG were predicted to require less healthcare resources, given their reduced prevalence of CMPA symptoms at 3 years. In the base case, EHCF+LGG led to savings of at least €674 per child compared to AAF, EHWF, and RHF at 3 years, from both perspectives. Nutrition had the highest economic burden in CMPA, driven by hypoallergenic formulas and dietetic replacements costs. Results were robust to one-way and probabilistic sensitivity analyses. Conclusions EHCF+LGG was associated with more symptom-free time, higher immune tolerance, and lower costs.

THE MILK PROBLEM IN HEINER SYNDROME

<h3>Introduction</h3> Heiner syndrome (milk induced pulmonary hemosiderosis) is a rare, non-IgE-mediated hypersensitivity to cow's milk. Symptoms include pulmonary hemorrhage, iron deficiency anemia, and failure to thrive. Serum precipitins to cow's milk can be positive. The mainstay of treatment was historically dairy avoidance, now with the addition of corticosteroids and sometimes immunosuppressants. <h3>Case Description</h3> An 18-month-old boy with Trisomy 21 was admitted with hypoxia, hemoptysis, pulmonary infiltrates, and anemia. Prior to admission, he had failure to thrive, constipation, bloody stools and cough. His BAL showed pulmonary hemosiderosis. He was started on an amino acid-based formula. The family was counseled about a dairy-free diet, on which he gained weight gain and cough resolved. He was not sensitized to milk based on skin and serum testing. Precipitins were positive to milk and 3 component proteins, and he was diagnosed with Heiner syndrome. He had 3 additional episodes of pulmonary hemorrhage. Two were likely viral-induced, while eating ice cream was the culprit for one. Given recurrent pulmonary hemorrhage, he was started on rituximab with a good response. <h3>Discussion</h3> This case adds to the limited literature regarding Heiner syndrome and highlights the potential role for immunomodulators like rituximab, as the presence of IgG to milk proteins suggests a humoral defect. Additionally, this case supports the recent description of an increased risk for pulmonary hemorrhage with Trisomy 21. Heiner syndrome, although rare, should be considered with pulmonary hemosiderosis especially in patients with Trisomy 21, as a dairy-free diet may aid in management.

Apports calciques chez l’enfant suivi pour allergie aux protéines du lait de vache : évaluation et conseils pratiques en consultation

Physicians have to pay attention to the dietary management of the children with a cow's milk proteins allergy (CMPA), beyond the avoiding rules and the prescription of a specific formula. Risk of a lack of calcium intake is higher for these patients who do not consume cow's milk, usually the main source of calcium. It's important to easily assess calcium intake during the consultation and to advice caregivers to prevent this deficient risk. Up to the age of 6 months, child is fed with formulas adapted without cow's milk protein (an extensively hydrolyzed formula (EHF), an amino acid-based formula (AAF) or a hydrolyzed rice protein formulas (HRPF)), that ensure an adequate intake of average 200mg of calcium per day. With food diversification, child has to daily drink over 400ml (optimally 700ml) of these formulas; few power spoons of EHF, AAF or HRPF could be added to puree and compotes. To obtain daily recommended diet, specific desserts without milk (available in pharmacy) or with plant based diet products may be helpful (available in supermarket). After 2 or 3 years old, EHF, AAF or HRPF are less consumed (tasteless and lassitude) and these desserts are an attractive alternative to ensure an intake of 450mg of calcium per day. For elder patients with CMPA, other dietary options as calcium rich waters and calcium supplementation with tablets could be useful.