Cow's Milk Protein Allergy In Infants Research Articles

Impact of the 2022 national formula shortage on clinical decision-making of healthcare providers in switching amino acid formulas for infants with cow's milk protein allergy: a survey-based study.

In 2022, the United States experienced a national shortage of infant formula due to a global supply chain crisis and a large-scale domestic formula recall. The existing literature on healthcare providers' (HCPs) clinical decision-making during formula shortages is limited. This study aims to analyze the factors influencing pediatric HCP clinical decision-making when switching between amino acid formulas (AAF) for managing cow's milk protein allergy (CMPA) in infants under 24 months of age during an unprecedented national formula shortage. The study included pediatric HCPs with experience managing CMPA in infants and toddlers under 24 months during the formula shortage from January 2022 to November 2022. A de-identified survey comprising 26 questions examining driving factors used in clinical decision-making was administered to pediatric HCPs using a real-time mobile data collection tool. Among the surveyed pediatric HCPs (n = 75), the factors most frequently considered as "extremely important" when switching to another AAF included safety (85%), tolerability (73%), and efficacy (83%). No statistically significant differences were found in HCP ratings among the listed examined factors of the four AAFs. The availability of specific formulas was the only factor that exhibited a statistically significant difference in perceived performance among pediatric HCPs when comparing the four AAFs (p < 0.05). This study elucidates the crucial aspects that influenced pediatric HCPs' selection of AAFs for CMPA management during the 2022 formula shortage. The findings highlight the significance of safety, tolerability, efficacy, and availability in the pediatric HCP decision-making processes.

Short-term symptom improvement in infants with suspected cow's milk protein allergy using amino acid formula: a prospective cohort analysis.

Cow's milk protein allergy (CMPA) occurs commonly in infants. While the long-term efficacy of amino acid formulas for managing CMPA is well-established, there is limited data on the short-term symptom improvement of using amino acid formula (AAF). This study aimed to determine the short-term effects of managing suspected CMPA in infants aged 6 months and under using a commercial AAF. Healthcare providers who treated infants with suspected CMPA aged 6 months or younger (n = 104) provided de-identified survey data in this prospective study. Healthcare providers scored symptoms for severity from 0 to 3 (none, low, moderate, severe) before using a commercial AAF at Visit 1 and at Visit 2 (3-6 weeks later). Gastrointestinal (94%), skin (87%), respiratory (86%), and uncategorized symptoms (89%) improved from AAF initiation, and these findings were consistent across different follow-up visit durations. This study is the most extensive prospective analysis conducted in the United States examining the short-term change in suspected CMPA symptoms using an AAF. These findings suggest that AAF may decrease the severity of suspected CMPA symptoms in infants 6 months or younger, often by the next follow-up visit. Further randomized controlled trials are required to confirm these initial findings.

PE-30: The Prevalence of Cow’s Milk Protein Allergy in Infants with Gastroschisis and Intestinal Failure type 2 and 3

Introduction: The prevalence of cow’s milk protein allergy (CMPA) in infants with gastroschisis has been reported as high as 45% [1], which is significantly higher than in the general infant population (0.5-1% of breast fed babies and 5-7% in formula-fed babies)[2]. We aimed to define the prevalence of CMPA in infants with gastroschisis and type 2 or 3 intestinal failure (IF) and compare this to other groups of infants with type 2 or 3 IF. Methods: We obtained parenteral nutrition (PN) prescriptions for infants born between July 2015 and June 2020 who had been on PN for more than 28 days (with type 2 or 3 IF) in our tertiary intestinal rehabilitation centre. We only included infants presenting in the first year of life with type 2 or 3 IF related to a gastrointestinal disorder, other than enteropathies. We recorded the underlying cause of IF and the number of patients clinically diagnosed with CMPA. The diagnosis of CMPA was made by the clinical team on the basis of gastrointestinal symptoms, presence of macroscopic blood in the stools and lack of any other alternative diagnosis with symptom resolution after initiation of a hydrolysed or amino acid based formula. We then obtained the feeding records of the patients and noted the number of infants on a hydrolysed and amino acid based formula during their hospitalisation and at the latest dietetic follow up. Results: Of 112 infants assessed, 23 (21%) were diagnosed with gastroschisis and 29 (26%) with necrotising enterocolitis (NEC); 25/29 (86%) of these were surgically managed. CMPA was diagnosed in 3/23 (13%) infants with gastroschisis, 5/25 (20%) of infants with surgically managed NEC and 5/64 (8%) of infants with other causes of type 2 and 3 IF. Out of 23 patients with gastroschisis, only one was discharged on home PN with no concerns of CMPA. Of the total 112 infants, 98 (88%) presented with type 2 IF and only 7 (7%) were also diagnosed with CMPA, while 14 (14%) infants were discharged on home PN and 6 (43%) were also diagnosed with CMPA. An amino acid based formula was trialled in 30/112 (27%) infants at some point during their hospitalisation. A hydrolysed formula was used in 54/112 (48%) infants with type 2 or 3 IF, in order to treat fat and sugar malabsorption, with 57% of children continuing to take a hydrolysed formula at the last recorded dietetic follow up. Three out of the 13 infants with CMPA (two with gastroschisis) have tolerated a dairy containing diet later on. Conclusions: The prevalence of CMPA in infants with gastroschisis and type 2 or 3 IF is much lower than previously reported. CMPA is most prevalent in infants with surgically managed NEC and type 2 or 3 IF, whilst the prevalence of CMPA in type 3 IF in general is significantly higher. The use of hydrolysed formula for the management of malabsorption may be masking the diagnosis of CMPA in children with type 2 IF.

Effect of maternal immune level at different pregnancy stages on cow's milk protein allergy in infants

OBJECTIVE To study the association between maternal Th1/Th2 immune level at different pregnancy stages and cow's milk protein allergy (CMPA) in infants. METHODS The healthy women with a singleton pregnancy, as well as their offspring, who attended Yidu Central Hospital of Weifang and Qingzhou Traditional Chinese Medicine Hospital from July 2016 to December 2018 were enrolled. The maternal levels of interleukin-2 (IL-2), interferon gamma (IFN-γ), interleukin-4 (IL-4), and interleukin-10 (IL-10) at the second and third trimesters of pregnancy were measured. A CMPA questionnaire survey was conducted within one year after birth. Food avoidance and cow's milk oral challenge tests were performed in infants suspected of CMPA. The 48 infants who met the diagnostic criteria for CMPA were included in the observation group, and the remaining 977 normal infants were included in the control group. A univariate analysis was performed on the infants with CMPA. A Poisson regression analysis was used to determine the association between maternal Th1/Th2 immune factors at different pregnancy stages and CMPA. RESULTS The detection rate of CMPA was 4.68%. The clinical manifestations included the symptoms of the digestive system, skin, and respiratory system and other symptoms. The univariate analysis showed that compared with the control group, the observation group had significantly higher incidence rates of maternal food allergy and maternal history of allergic diseases (P<0.05) and a significantly lower breastfeeding rate (P<0.05). The observation group had significantly lower maternal levels of IL-2 (second and third trimesters) and IFN-γ (third trimester) than the control group (P<0.05). Maternal low IFN-γ at the third trimester and maternal low IL-2 at the second and third trimesters were significantly associated with CMPA in infants (P<0.05). After correction of the factors of breastfeeding, maternal food allergy, and maternal history of allergic diseases, it was found that maternal low IL-2 and IFN-γ at the third trimester were still significantly associated with CMPA in infants (P<0.05). CONCLUSIONS The maternal decrease in Th1 level at the third trimester of pregnancy may lead to the change in fetal immunity and thus increase the risk of CMPA in offspring.

Assessment of cows milk-related symptom scoring awareness tool in young Turkish children.

The diagnosis of cows milk protein allergy (CMPA) is not always easy. Cow's Milk-related Symptom Score (CoMiSS) has been developed to raise the awareness of CMPA among the primary health-care providers. In this study, we aimed to evaluate the validity of CoMiSS as a diagnostic approach of CMPA in infants in our country. Infants with a CoMiSS of more than 12 points were included. An elimination diet was implemented in these infants for 4 weeks, and CoMiSS was reapplied. Infants with a reduction of ≥3 points in CoMiSS were considered responsive to the elimination diet, and an open oral challenge test was performed. Infants with symptom recurrence were diagnosed with CMPA. The study included 168 infants. When they were included in the study, the first CoMiSS score was 13.6 ± 1.9. After the elimination diet, the number of responsive infants was 154 (91.7%). Of the infants, 91 (54.2%) were diagnosed with CMPA with positive challenge. The majority of the patients diagnosed with CMPA presented with gastrointestinal and/or dermatological symptoms (80.3%). Positive family history of allergy was more prevalent in CMPA(+) infants (P < 0.001). The mean atopic dermatitis score was higher in CMPA(+) infants (P = 0.001). Eosinophilia and cows milk-specific IgE (CM-sIgE) positivity were more prevalent in infants with CMPA (P = 0.01 and P < 0.001, respectively). CoMiSS is a valuable tool to evaluate CMPA in primary care. The presence of multiple symptoms, especially skin involvement, helps to recognise infants with CMPA. Family history and eosinophilia also support the diagnosis of CMPA.

Confirmed Hypoallergenicity of a Novel Whey-Based Extensively Hydrolyzed Infant Formula Containing Two Human Milk Oligosaccharides

Background: We sought to determine whether an extensively hydrolyzed formula (EHF) supplemented with two human milk oligosaccharides (HMO) was tolerated by infants with cow’s milk protein allergy (CMPA). Methods: A whey-based EHF (Test formula) containing 2′fucosyl-lactose (2′FL) and lacto-N-neotetraose (LNnT) was assessed for clinical hypoallergenicity and safety. The Control formula was a currently marketed EHF without HMO. Children with CMPA, aged 2 months to 4 years, were assessed by double-blind, placebo-controlled food challenges (DBPCFC) to both formulas, in randomized order. If both DBPCFC were negative, subjects participated in a one-week, open food challenge (OFC) with the Test formula. Symptoms and adverse events were recorded. Hypoallergenicity was accepted if at least 90% (with 95% confidence intervals) of subjects tolerated the Test formula. Results: Of the 82 children with CMPA that were screened, 67 (intention-to-treat [ITT] cohort—mean age 24.5 ± 13.6 months; range 2–57; 45 [67.2%] male) were randomized to receive either the Test or the Control formula during the first DBPCFC. Of these, 64 children completed at least one DBPCFC (modified intention-to-treat [mITT] cohort). Three children were excluded due to protocol deviations (per protocol [PP] cohort; n = 61). There was one allergic reaction to the Test, and one to the Control formula. On the mITT analysis, 63 out of 64 (98.4%; 95% CI lower bound 92.8%), and on the PP analysis 60 out of 61 (98.4%; 95% CI lower bound 92.5%) participants tolerated the Test formula, confirming hypoallergenicity. Conclusion: The whey-based EHF supplemented with 2′FL and LNnT met the clinical hypoallergenicity criteria and can be recommended for the management of CMPA in infants and young children.

Frequency of cow milk protein allergy in children during the first 2 years of life in Damietta Governorate

Background Many research studies have been done to explore the prevalence of cow milk allergy. Aim of the work The aim of this study is to determine the frequency of cow’s milk protein allergy (CMPA) among children of Damietta Governorate during the first 2 years of life. Patients and methods A cross-sectional study with nonsystemic random sampling was conducted on 1000 children in the first 2 years of age, comprising 512 male and 488 female exposed to cow milk or its products either directly or indirectly, attending outpatient clinics of Al Azhar University Hospital in New Damietta. Each included infant was subjected to history taking and clinical examination, and suspected cases from history and examination were subjected to skin prick test, specific immunoglobulin E (IgE) for cow’s milk protein, oral food challenge, and food elimination tests. Results In the present work, there was a male predominance among the suspected group (58.5% males and 41.5% females). We found that infants from urban regions were more affected than those from rural regions (61.76% of the confirmed cases were from urban areas and 38.24% from rural regions). We found that the risk of CMPA declined in exclusively breast-fed infants. The clinical manifestations in infants with suspected CMPA were variable, and the main presenting feature was gastrointestinal tract manifestations (84% of the cases) (P Conclusion This study showed that the frequancy of CMPA in infants in the first 2 years of life in Demietta Governrate was 3.4%, as confirmed by positive food elimination and oral food challenge tests, and the IgE-mediated CMPA was more common, as 67.6% of cases had IgE-mediated CMPA.

Towards Optimised Management of Cow’s Milk Protein Allergy

This symposium took place during the 2018 meeting of the European Academy of Allergy and Clinical Immunology (EAACI). Focussing on the fundamental issues of suboptimal management of patients with cow’s milk protein allergy (CMPA), the speakers discussed key themes for optimising management. Prof Madrazo-de la Garza evaluated the challenges of diagnosis and management of CMPA in infants. Nonspecific symptoms, indicative of other conditions, mean that CPMA is often misdiagnosed as lactose intolerance, a rare condition in infants. Increased awareness of CMPA symptoms and a clear distinction from lactose intolerance may facilitate earlier, accurate diagnosis and implementation of appropriate dietary interventions. Dr Nutten followed by exploring variability in the composition of commercialised extensively hydrolysed formulas (eHF) intended for the management of CMPA and the associated potential clinical impact. Large variations in peptide profiles and residual allergenicity reflect a lack of definition for eHF composition. Although the clinical trials required to confirm the efficacy of eHF by demonstrating tolerance in &gt;90% of infants with CMPA are performed, composition analyses for characterisation, quality control, and reproducibility are crucial for ensuring safe and suitable products throughout the product lifecycle. Prof O’Mahony concluded the meeting by focussing on the importance of the gut microbiome in food allergy. The establishment of a stable gut microbial community closely tracks host growth and immune development. Delayed or altered establishment leads to microbiome immaturity, which has been associated with an increased risk of food allergies. Nutritional strategies, such as the use of eHF containing lactose, to support microbiome development complement existing CMPA treatment.

Expert panel on practice patterns in the management of cow’s milk protein allergy and associated economic burden of disease on health service in Turkey

Aims: To evaluate practice patterns in the management of cow’s milk protein allergy (CMPA) and associated economic burden of disease on health service in Turkey.Materials and methods: This study was based on experts’ views on the practice patterns in management of CMPA manifesting with either proctocolitis or eczema symptoms and, thereby, aimed to estimate economic burden of CMPA. Practice patterns were determined via patient flow charts developed by experts using the modified Delphi method for CMPA presented with proctocolitis and eczema. Per patient total 2-year direct medical costs were calculated, including cost items of physician visits, laboratory tests, and treatment.Results: According to the consensus opinion of experts, 2-year total direct medical cost from a payer perspective and societal perspective was calculated to be $US2,116.05 and $US2,435.84, respectively, in an infant with CMPA presenting with proctocolitis symptoms, and $US4,001.65 and $US4,828.90, respectively, in an infant with CMPA presenting with eczema symptoms. Clinical nutrition was the primary cost driver that accounted for 89–92% of 2-year total direct medical costs, while the highest total direct medical cost estimated from a payer perspective and societal perspective was noted for the management of an exclusively formula-fed infant presenting either with proctocolitis ($US3,743.85 and $US4,025.63, respectively) or eczema ($US6,854.10 and $US7,917.30, respectively). The first line use of amino acid based formula (AAF) was associated with total direct cost increment $US1,848.08 and $US3,444.52 in the case of proctocolitis and eczema, respectively.Limitations: Certain limitations to this study should be considered. First, being focused only on direct costs, the lack of data on indirect costs or intangible costs of illness seems to be a major limitation of the present study, which likely results in a downward bias in the estimates of the economic cost of CMPA. Second, given the limited number of studies concerning epidemiology and practice patterns in CMPA in Turkey, use of expert clinical opinion of the panel members rather than real-life data on practice patterns that were used to identify direct medical costs might raise a concern with the validity and reliability of the data. Also, while this was a three-step study with six experts included in the first stage (developing local guidelines for diagnosis, treatment, and follow-up of infants with CMPA in Turkey) and 410 pediatricians included in the second stage (a cross-sectional questionnaire-survey to determine pediatricians’ awareness and practice of CMPA in infants and children), only four members were included in the present Delphi panel, which allows a limited discussion. Third, lack of sensitivity analyses and exclusion of indirect costs and costs related to alterations in quality of life, behavior of infants, and general well-being of infants and their parents from the cost-analysis seems to be another limitation that may have caused under-estimation of relative cost-effectiveness of the formulae. Fourth, calculation of costs per local guidelines rather than real-life practice patterns is another limitation that, otherwise, would extend the knowledge achieved in the current study. Notwithstanding these limitations, the present expert panel provided practice patterns in the management of CMPA and an estimate of the associated costs, depending on the symptom profile at initial admission for the first time in Turkey.Conclusions: In conclusion, in providing the first health economic data on CMPA in Turkey, the findings revealed that CMPA imposes a substantial burden on the Turkish healthcare system from both a payer perspective and societal perspective, and indicated clinical nutrition as a primary cost driver. Management of infants presenting with eczema, exclusively formula-fed infants, and first line use of AAF were associated with higher estimates for 2-year direct medical costs.

The establishment of cow's milk protein allergy in infants is related with a deficit of regulatory T cells (Treg) and vitamin D.

Cow's milk protein allergy (CMPA) is the most common food allergy in infants. However, little is known about which specific immune mechanisms are related with the CMPA onset. The objective was to investigate which immune alterations constitute differential factors between allergy and tolerance, and hence could be implicated in the CMPA establishment in infants. An extensive analysis of immune subsets, including Treg and cytokine-secreting cells was performed in blood samples from 28 infants younger than 9 mo obtained 1-4 d after the first adverse reaction to milk. Less than 4 d after first allergic reaction, infants who developed CMPA had decreased Treg counts and increased frequency of IL4-secreting CD4 T cells compared to controls. The deficit of Tregs was correlated with decreased serum levels of vitamin D. Values of Tregs, IL4-secreting cells and vitamin D were good predictors of CMPA diagnosis. Basal vitamin D levels in CMPA infants also predicted those CMPA patients developing spontaneous tolerance in the first year. Establishment of CMPA in infants was related with lower Treg and vitamin D levels. These immune alterations would be crucial factors behind the CMPA establishment and they could constitute a therapeutic target for treatment of CMPA.

Cow`s milk protein allergy awareness and practice among Turkish pediatricians: A questionnaire-survey.

Yüce A, Dalgıç B, Çullu-Çokuğraş F, Çokuğraş H, Kansu A, Alptekin-Sarıoğlu A, Şekerel BE. Cow`s milk protein allergy awareness and practice among Turkish pediatricians: A questionnaire-survey. Turk J Pediatr 2017; 59: 233-243. Region-specific recommendations for the prevention, diagnosis, and treatment of cow`s milk protein allergy (CMPA) are not available in Turkey. This cross-sectional questionnaire-survey was designed to evaluate CMPA awareness and practice among Turkish pediatricians. A total of 410 pediatricians were included based on their voluntary participation. Questionnaires elicited demographic data and pediatricians` awareness and practice of CMPA in infants and children. Atopic dermatitis (91.5%), diarrhea (88.0%) and significant blood in stool (85.9%) were the most common symptoms considered suggestive of CMPA. Continuation of breast feeding via elimination of CMP containing products from maternal diet was the most commonly selected (79.0%) therapeutic option in exclusively breast-fed infants diagnosed with CMPA. Amino acid-based formula was the most commonly selected formula in a non-exclusively breast-fed infant with CMPA, for infants presenting with anaphylaxis (58.8%), enterocolitis (40.7%) or multiple food allergies (52.0%), and also for at-risk infants (40.2%). Earliest time to re-challenge was identified to be 6 months by 52.0% of pediatricians. In conclusion, our findings revealed high awareness of CMPA among Turkish pediatricians in terms of clinical presentation and first priority diagnostic tests. However, CMPA practice among Turkish pediatricians needs to be improved in terms of avoidance of other mammalian milks, selection of therapeutic formulas among non-exclusively breast-fed infants and at-risk infants consistent with guideline-based indications and cost-effectivity.

The clinical characteristics and related factors of cow's milk protein allergy in infants less than 3 months old in Guangxi District

Objective To study the clinical characteristics and risk factors of cow's milk protein allergy(CMPA) in infants less than 3 months old in Guangxi District. Methods From July 1, 2012, to December 30, 2014, infants less than 3 months old suspected of CMPA visiting the pediatric outpatient department of Maternal and Children Hospital of Guangxi Zhuang Autonomous Region were recruited, which included initial diagnosis and being transported from peripheral hospitals.Observation scale was formulated, attending physician screened patients and their senior made a definite diagnosis.All the infants underwent diagnostic algorithms and were followed up constantly. Results A total of 137 cases were divided into allergy group(n=51) and control group(n=86). Two groups shared some common symptoms such as diarrhea, constipation, bloody stool, stomachache, gastroesophageal reflux(GER), indigestion, anorexia, feeding difficulties.Between the allergy group and control group the parameters such as feeding patterns (including breast feeding, mix feeding, formula feeding), improper deeding of food supplement, long- term use of antibiotics in neonatal period and parental atopy showed no significant differences(P>0.05). The parameters in neonatal period including GER[20 cases(39.2%) vs.7 cases(8.1%)], intake of cow's milk formula[51 cases(100%)vs.71 cases(82.6%)], feeding intolerance(including GER)[17 cases(33.3%)vs.11 cases(12.8%)], gut infection[8 cases(15.7%)vs.4 cases(4.7%)], transfusion of blood or/and bloody products[12 cases(23.5%)vs.11 cases(12.8%)] showed statistically significant differences between the allergy group and control group(χ2=19.538, P=0.000; χ2=9.989, P=0.002; χ2=8.308, P=0.004; χ2=4.691, P=0.030; χ2=5.198, P=0.023). Conclusion Symptoms of CMPA in infants no more than 3 months old involve mainly digestive system such as diarrhea, bloody stool, GER.Intake of cow milk formula in neonatal period play an important role in triggering CMPA. Key words: Cow's milk protein allergy; Cow milk formula; Infant; Diarrhea; Bloody stool

Elimination diets and dietary interventions for the management of food allergies Elimination diets and dietary interventions for the management of food allergies

The primary therapy for food allergy is strict avoidance of the offending food or foods. Dietary restriction should be tailored to meet the nutritional requirements of each patient.Patients should be educated on how to avoid allergens safely by understanding terminology for common ingredients and how to read food labels. Information regarding safe, cost-effective and freely available substitutes for the avoided foods should be provided. Patients should be re-evaluated at regular intervals to see if they have developed tolerance. Mothers of infants with cow’s milk protein allergy (CMPA) who are breastfeeding should be supported and encouraged to continue breastfeeding. Partially hydrolysed infant formulas are not hypoallergenic (tolerated by 90% of subjects with proven CMPA) and are therefore not recommended for the treatment of CMPA, but may have a role in prevention of eczema or CMPA in high-risk individuals. Some extensively hydrolysed and amino-acid-based formulas are truly hypoallergenic. The recommended feed of choice for the dietary management of mild-to-moderate CMPA in infants not breastfed is an extensively hydrolysed cow’s milk formula. The recommended formula for the dietary management of non-breastfed infants and children with known severe CMPA is an amino-acid-based formula. Soya-based formulas may be useful in infants with immunoglobulin E (IgE)-mediated CMPA with proven tolerance to soya, and some cases of mild-to-moderate non-IgE-mediated CMPA, bearing in mind the increased risk of co-reactivity between CMPA and soya allergy in non-IgE-mediated conditions. Other mammalian milks and plant-based milks, including rice and oat milks, are not suitable as sole nutrition for cow’s milk protein allergic individuals.

Non-IgE-Mediated Cow Milk Allergy Is Linked to Early Childhood Clusters of Commonly Seen Illnesses

There are few established diagnostic tools to define non-IgE-mediated food hypersensitivity reactions. Cow milk protein allergy (CMPA) is a multisystem disorder affecting the gastrointestinal, skin, and lower and upper airway systems. This link is frequently missed because of subspecialty evaluation of the multisystem effects individually. The authors hypothesize that a more global evaluation based on a simple scored questionnaire will reveal this link. Over an 18-month period, children younger than 2 years with non-IgE-mediated CMPA were identified. A symptom questionnaire was developed and scored and also applied to a control population. The prevalence of symptoms in each group was compared and a cumulative score was determined. Symptoms evaluated included gastrointestinal, aerodigestive, lower airway, and skin symptoms. A positive response was scored 1 and a negative response scored 0. Significant differences in prevalence rates between CMPA and control populations were noted, particularly in aerodigestive symptoms. There were marked differences in cumulative score between populations (P < .001). The authors identified a cut-off score at which there was close to 80% sensitivity and 90% specificity for distinguishing CMPA from a control population. A global evaluation of multiple systems can be an important diagnostic tool in determining CMPA in infants.

FECAL CALPROTECTIN AND COW'S MILK PROTEIN ALLERGY IN INFANTS

Calprotectin, a 36.5 kiloDalton protein released into the intestinal lumen by macrophages and neutrophils, has been shown to be useful in determining disease activity and treatment response in intestinal inflammatory conditions such as inflammatory bowel disease. Cow's milk protein allergy (CMPA) is a common gastrointestinal problem of infancy associated with rectal bleeding, emesis, diarrhea, and eczema. We hypothesized that fecal calprotectin is a useful screening test to evaluate for resolution of CMPA in infants. A pilot trial was performed in six infants less than 90 days of age with rectal bleeding and other symptoms consistent with cow's milk protein allergy. Fecal calprotectin levels were determined by ELISA assay at baseline, 3, and 6 weeks after placement on a protein hydrolysate formula. All infants improved clinically and rectal bleeding resolved within 6 weeks after conversion to a hydrolysate formula. Initial fecal calprotectin levels ranged from 135-1537 mg/L (mean 557 mg/L) and decreased to a range of 42-219 mg/L (mean 163 mg/L) after 6 weeks on protein hydrolysate formula. A control patient with no symptoms of CMPA maintained fecal calprotectin values between 97 and 129 mg/L throughout the study. The results of this pilot trial suggests that fecal calprotectin may be a useful screening test for treatment response to protein hydrolysate formula; however, further studies with a larger number of patients are necessary to determine the utility of this test in infants with CMPA.

Vomiting and gastric motility in infants with cow's milk allergy.

Regurgitation and vomiting are common manifestations of cow's milk protein allergy (CMPA) in infants and are usually ascribed to gastroesophageal reflux (GER). Gastric anaphylaxis can induce antral dysmotility in the rat, and therefore the hypothesis for the current study was that cow's milk in sensitized infants may impair antral motility, thereby promoting GER and reflex vomiting. Seven vomiting infants with CMPA and nine with primary GER underwent a challenge with cow's milk formula. Electrogastrography (EGG) was used to measure the spectral frequency (bradygastria = 1.5-2.4 cycles per minute [cpm], normogastria = 2.5-3.9 cpm, tachygastria = 4.0-9.0 cpm) and the postprandial-to-fasting power ratio of gastric electrical activity, whereas gastric half-emptying time (T1/2) was measured by electrical impedance tomography (EIT). In CMPA and GER, respectively, during fasting, the frequency distribution (mean +/- SD) of the EGG was as follows: normogastria 47.9%+/-12.5% versus 52.2%+/-9.8%, bradygastria 24.1%+/-5.7% versus 22.8%+/-8.3%, and tachygastria 28.0% 8.5% versus 25.0% 8.3%. In contrast, after the cow's milk challenge, the difference between the two groups was statistically significant: normogastria 33.1%+/-8.8% versus 70.6%+/-8.6% (P < 0.0001). bradygastria 38.0%+/-15.5% versus 15.7%+/-5.2% (P = 0.002), and tachygastria 28.9%+/-10.6% versus 13.4%+/-4.6% (P = 0.001. The postprandial/ fasting power ratio (mean +/- SD) was 3.2+/-1.9 in CMPA and 8.1+/-2.1 in GER (P < 0.0001). Gastric T1/2 (mean +/- SD) of the cow's milk meal was 89.0+/-26.3 minutes versus 54.0+/-12.6 minutes (P = 0.003). In infants with GER all EGG parameters and gastric T1/2 were similar to that in 10 healthy control infants. In sensitized infants, cow's milk induces severe gastric dysrhythmia and delayed gastric emptying, which in turn may exacerbate GER and induce reflex vomiting. Electrogastrography and EIT can be useful in the assessment of vomiting, GER, and CMPA in infants.

Vomiting and Gastric Motility in Infants With Cow's Milk Allergy

ABSTRACTBackgroundRegurgitation and vomiting are common manifestations of cow's milk protein allergy (CMPA) in infants and are usually ascribed to gastroesophageal reflux (GER). Gastric anaphylaxis can induce antral dysmotility in the rat, and therefore the hypothesis for the current study was that cow's milk in sensitized infants may impair antral motility, thereby promoting GER and reflex vomiting.MethodsSeven vomiting infants with CMPA and nine with primary GER underwent a challenge with cow's milk formula. Electrogastrography (EGG) was used to measure the spectral frequency (bradygastria = 1.5—2.4 cycles per minute [cpm], normogastria = 2.5–3.9 cpm, tachygastria = 4.0–9.0 cpm) and the postprandial‐to‐fasting power ratio of gastric electrical activity, whereas gastric half‐emptying time (T½) was measured by electrical impedance tomography (EIT).ResultsIn CMPA and GER, respectively, during fasting, the frequency distribution (mean ± SD) of the EGG was as follows: normogastria 47.9% ± 12.5% versus 52.2% ± 9.8%, bradygastria 24.1% ± 5.7% versus 22.8% ± 8.3%, and tachygastria 28.0% ± 8.5% versus 25.0% ± 8.3%. In contrast, after the cow's milk challenge, the difference between the two groups was statistically significant: normogastria 33.1% ± 8.8% versus 70.6% ± 8.6% (P &lt; 0.0001), bradygastria 38.0% ± 15.5% versus 15.7% ± 5.2% (P = 0.002), and tachygastria 28.9% ± 10.6% versus 13.4% ± 4.6% (P = 0.001. The postprandial/fasting power ratio (mean ± SD) was 3.2 ± 1.9 in CMPA and 8.1 ± 2.1 in GER (P &lt; 0.0001). Gastric T½ (mean ± SD) of the cow's milk meal was 89.0 ± 26.3 minutes versus 54.0 ± 12.6 minutes (P = 0.003). In infants with GER all EGG parameters and gastric T½ were similar to that in 10 healthy control infants.ConclusionsIn sensitized infants, cow's milk induces severe gastric dysrhythmia and delayed gastric emptying, which in turn may exacerbate GER and induce reflex vomiting. Electrogastrography and EIT can be useful in the assessment of vomiting, GER, and CMPA in infants.