Diagnosis Of Cow's Milk Protein Allergy Research Articles

Clinical characteristics, laboratory findings, and tolerance acquisition in infants with cow's milk protein allergy in a private center in Lima, Peru for the period 2021-2022.

Cow's milk protein allergy (CMPA) remains relatively understudied in Latin America. In this observational study, we enrolled 64 patients with a median age of 3 months, of whom 60% were male. Patients included had a history of IgE-mediated reactions with IgE sensitization or non-IgE-mediated reactions or symptoms following exposure to cow's milk. They underwent skin prick test, ImmunoCAP, fecal calprotectin (FC), and fecal eosinophil-derived neurotoxin (EDN), in addition to double-blinded placebo-controlled oral food challenges (DBPCFC), with clinical evolution and tolerance acquisition observed over 1 year. Malnutrition was present in 78.1% of patients, and 87.5% had a family history of atopy, with 51.6% receiving exclusive breastfeeding. Gastrointestinal manifestations were prevalent in 90.6% of patients, followed by dermatological manifestations (10.9%), with only 2 experiencing anaphylaxis. IgE-mediated CMPA was observed in only six patients. In those with non-IgE-mediated CMPA, FC had a median of 284 mg/dL (IQR: 138.5-415.5), while EDN had a median of 508.5 mg/dL (IQR: 160.25-868). One year after diagnosis, median FC significantly decreased (p < 0.0001), and malnutrition prevalence reduced to 17.1%. Moreover, 81% of patients acquired tolerance following DBPCFC, with 52% utilizing nutritional replacement formulas at diagnosis. Notably, 94% of those extensively hydrolyzed casein-based formulas achieved tolerance (p = 0.08). Our findings provide a foundational framework for future investigations into CMPA diagnosis, tolerance acquisition, and the utilization of hypoallergenic formulas tailored to the unique characteristics of our region.

What is Known About Cow's Milk Protein Allergy in Preterm Infants?

Background: Cow's milk protein allergy (CMPA) is well described in term infants, as opposed to preterm infants. In preterm infants, CMPA shares many gastrointestinal symptoms with necrotizing enterocolitis (NEC). Objectives: To evaluate the presentation of CMPA in preterm infants and to investigate the different diagnostic and therapeutic options. Materials and Methods: We searched for the relevant literature using the medical databases PubMed, Web of Science, and the Cochrane Library. We performed a post hoc analysis on the 25 case reports included in this study. Results: Literature was scarce and heterogeneous. The majority of preterm infants with CMPA were exposed to bovine-based milk proteins before the development of symptoms. The most common clinical manifestations were bloody stools, vomiting, and abdominal distension. Of the 25 cases, only 7 (28%) retained human milk in their diet after diagnosis. In the larger studies, no study has human milk as primary feeding choice after diagnosis. Conclusions: Preterm infants exposed to a type of cow's milk-based formula in their first days of life have a higher risk of developing CMPA. Most of the preterm infants are no longer fed with human milk after the diagnosis of CMPA is made, which is in contrast with current nutrition guidelines in preterm infants. We strongly advocate that human milk with mothers on a cow's milk-free diet is the first choice of feed after the diagnosis of CMPA. Prospective studies are necessary to obtain more information regarding clinical presentation, diagnostic tools, and therapeutic approaches.

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.

8th ABM/EABM European Regional Conference May 11–13, 2023 Split, Croatia

Breastfeeding MedicineAhead of Print AbstractsFree Access8th ABM/EABM European Regional Conference May 11–13, 2023 Split, CroatiaPublished Online:14 Apr 2023https://doi.org/10.1089/bfm.2023.29239.abstractsAboutSectionsPDF/EPUB Permissions & CitationsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Oral Presentations1. Systematic Review and Meta‐analysis of the effect of relaxation interventions on breastmilk quantity and maternal mental healthIlana Levene1, Nurul Husna Mohd‐Shukri2, Frances O'Brien3, Maria Quigley1, Mary Fewtrell41National Perinatal Epidemiology Unit, University of Oxford, United Kingdom2Universiti Putra Malaysia, Malaysia3John Radcliffe Hospital, United Kingdom4Institute for Child Health, University College London, United KingdomBackground: Breastfeeding is an important public health goal. Rates of breastfeeding are low and geographically variable. Maternal stress could impair lactation, through hormonal, neuronal or behavioural pathways.Objectives: This study aims to analyse the effect of relaxation interventions on lactation outcomes.Methods: Systematic review and meta‐analysis were performed to address the question: “in lactating mothers, does relaxation therapy, compared to standard care, improve milk quantity and maternal mental health?” Randomised studies with interventions designed to achieve relaxation through reduction in mind‐stress were included. Fixed‐effects meta‐analysis was used. A standardised mean difference (SMD) was calculated if the units of measurement varied between studies.Results: The search took place in August 2022. Twelve studies are included, with data from 1533 lactating parents. Interventions included guided relaxation, music and mindfulness. Seven studies measured milk quantity with summary SMD of 0.75. This is equivalent to an increase in daily breastmilk yield of 225ml, which is clinically significant. Five studies measured maternal anxiety and four measured maternal stress. The summary SMDs were −0.52 and −0.7 respectively, which are medium effect sizes. There was significant statistical heterogeneity in all outcomes.Conclusion: There is evidence for a clinically significant increase in breastmilk quantity and a moderate reduction in maternal stress and anxiety when a relaxation intervention is provided. Given the low potential harm and high availability of relaxation interventions, they can be recommended to lactating parents, particularly to those with concerns over milk quantity and/or stress.2. Knowledge, Attitudes and Practices on Breastfeeding and the first one thousand days of life among social and healthcare professionalsGabriella Tambascia1,2, Francesca Zambri1, Francesca Marchetti1,2, Annachiara Di Nolfi1,2, Jessica Preziosi1,2, Elise M. Chapin3 Stefania Solare3, Angela Giusti11National Center for Disease Prevention and Health Promotion, National Institute of Health, Rome, Italy2Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy3Italian National Committee for UNICEF, ItalyBackground: Healthcare professionals' (HCP) support and training on breastfeeding and the first one thousand days of life is an essential factor for successful breastfeeding.Objective: To describe the Knowledge, Attitudes and Practices (KAP) of social and healthcare professionals on breastfeeding and the first thousand days of life.Methods: During 2022, an e‐learning module was developed by the Italian National Institute of Health, in collaboration with UNICEF Italy and Local Health Authority of Rome (ASL Roma 5). A KAP pre‐assessment was carried out at course entrance, using a 37‐item questionnaire.Results: Data from 19315 professionals (Jan–Nov 2022) show a mean age of 42,6 and the most represented professions were general and pediatric nurses (37,38%), midwives (19,2%) and psychologists (11,7%). The median knowledge score was 81,8%. The most frequent incorrect answer (39,1%) was about breastfeeding duration. Likewise, 30,5% disagreed that breastfeeding can be continued beyond the second year of life. As for opinions, 65,2% of participants considered collecting donations of Breast‐milk Substitutes (BMS) in emergencies important, despite its not being recommended. Moreover, 44,3% disagreed that most medications can be used during breastfeeding. As for practices, 54,1% of respondents declared they often inform parents on the important role of fathers in managing household labor and childcare. Eighty‐nine percent thought that fathers do not lose their masculinity taking care for children.Conclusion: These results show a good level of knowledge at course entrance. Some common misconceptions, e.g. duration of breastfeeding, managing BMS donations in emergencies and the father's role in childcare, are still widespread.3. Maternal physical health and breastfeeding problems in Croatia: national online survey of new mothersLisa Amir1, Daniela Drandić2, Anita Pavicic Bosnjak3, Ana Vidović Roguljić4, Gill Thomson5, Irena Zakarija‐Grković61La Trobe University and Royal Women's Hospital, Australia2RODA‐ Parents in Action, Croatia3University Hospital Centre Zagreb, Croatia4Community Health Centre, Split‐Dalmatia County, Croatia5University of Central Lancashire, United Kingdom6University of Split School of Medicine, CroatiaBackground: Maternal physical symptoms are common in the postpartum period, yet these “hidden morbidities” receive little attention from health care providers. In addition, many mothers experience breastfeeding problems, including nipple pain and mastitis. While studies in several countries have provided prevalence estimates, there have been no studies in Croatia looking at maternal postpartum physical health.Objectives: To document maternal physical health and breastfeeding problems in the first six months after giving birth in Croatia.Methods: We conducted a cross‐sectional study using an online questionnaire between February and April 2022 among resident Croatian women who had enrolled in the RODA (‘Parents in Action’) online antenatal course. Women aged 18+ years, who had given birth in a Croatian maternity facility between February 2020 and December 2021 were eligible. The questionnaire contained 75 items, covering sociodemographic characteristics, hospital practices, community support, maternal mental and physical health.Results: Postpartum health and breastfeeding items were completed by 1760 participants. Major physical health issues were fatigue (28%; n = 487), back pain (14%; n = 252), and hemorrhoids (10%; n = 171). Urinary incontinence was a minor problem for 23% (n = 397), somewhat of a problem for 8% (n = 139) and a major problem for 4% (n = 67).The most common breastfeeding problems were nipple pain/damage 50% (n = 885), difficulty attaching 43%, (n = 761), low milk supply 28% (n = 490), mastitis 22% (n = 391), engorgement 22% (n = 393), breast refusal 22% (n = 381), and too much milk 22% (n = 380).Conclusion: Postpartum women in Croatia experienced many physical health challenges. The frequency of pain associated with breastfeeding is concerning.4. Questioning the usefulness of 24‐hour recall of exclusive breastfeedingKeiko Nanishi, Joseph Green, Akira Shibanuma, Hiroko HongoGraduate School of Medicine, the University of Tokyo, JapanBackground: The WHO recommends exclusive breastfeeding for the first six months, and it promotes the Ten Steps to Successful Breastfeeding (Ten Steps). It also recommends monitoring the proportion of infants under six months old fed exclusively with breastmilk during the previous 24 hours. Whether that 24‐hour recall usefully reflects the Ten Steps is unknown.Objective: To compare two indicators of infant feeding, exclusive breastfeeding since birth and 24‐hour recall, by quantifying each indicator's association with provision of the Ten Steps.Methods: Mothers in Japan who had had a healthy singleton delivery in the previous two years were surveyed online in August 2021. Because of Japan's recommendation to start complementary feeding five months after birth, 3,753 mothers with infants older than five months reported on their breastfeeding from birth to five months, and 1,029 mothers with infants under five months reported on their breastfeeding over the previous 24 hours. The strength of each indicator's association with provision of the Ten Steps was quantified as the area under the receiver operating characteristic curve (AUC).Results: Exclusive breastfeeding since birth (prevalence = 4.4%) was moderately‐well associated with provision of the Ten Steps: AUC = 0.72. In contrast, 24‐hour recall of exclusive breastfeeding under five months (prevalence = 31.6%) was only very weakly associated with provision of the Ten Steps: AUC = 0.59.Conclusion: The WHO's recommended indicator of exclusive breastfeeding (24‐hour recall) concealed the effectiveness of providing the WHO's Ten Steps. Using 24‐hour recall to evaluate breastfeeding‐promotion interventions may be inappropriate.5. Finding a path in a maze. Identification of an adverse reaction during lactation based on a case study of ergotamineKarolina MorzePrivate Clinic, Departament of Pharmacovigilance, PolandIntroduction: The article presents a lactating patient who contacted the pharmacy office to inquire about the alarming reaction to ergotamine. She was given ergotamine due to retention of lochia and during the treatment she experienced a severe nipple pain.Main Issue: The patient was unable to feed directly from the breast and bottle fed the baby with her own expressed milk. She was worried that the nipple pain would worsen and persist for a long time and was concerned that the situation would affect further lactation.Management: The pharmacist conducted an interview, prepared and analyzed the treatment timeline based on the reported symptoms [figure 1], provided information and possible solutions to the problem. A follow‐up was performed one, two, and 20 days after the consultation. Using Adverse Drug Reaction Probability Scale, the pharmacist identified a definite adverse event related to ergotamine intake – Raynaud syndrome in the nipple. As a result of the consultation, the patient decided to continue taking the drug, and wait for the symptom to resolve to resume direct feeding from the breast. She felt more confident and less worried with the medical supportive care.Conclusion: Ergotamine treatment caused a vasospasm in the nipple of the patient and resulted in a change in the way the infant was being fed. The situation affected the maternal ability to breastfeed, caused direct and indirect costs and negatively impacted the patient's quality of life. It had no apparent adverse effect on the baby and the situation did not impact the milk supply.6. Identifying indicators of a breastfeeding‐friendly city: A Delphi surveyMay Loong Tan1,5, Siew Cheng Foong1, Wai Cheng Foong1, Grace YW Tay2, Jacqueline J Ho1, Amal Omer‐Salim3, Elizabeth J O'Sullivan4, Fionnuala M McAuliffe51Department of Paediatrics, RCSI & UCD Malaysia Campus, Penang, Malaysia2IBCLC, Gloria Group Sdn Bhd, Penang, Malaysia3World Alliance for Breastfeeding Action, Malaysia4School of Biological, Health and Sports Science, Technological University Dublin, Ireland5UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, IrelandBackground: A breastfeeding‐friendly city is one with a synchronous and enabling environment for breastfeeding. There is currently no specific set of indicators of a breastfeeding‐friendly city. A scoping review and interviews with breastfeeding mothers identified numerous potential indicators of a breastfeeding‐friendly city.Objective: To determine a set of indicators of a breastfeeding‐friendly city through consensusMethods: A Delphi‐method survey in two rounds was used. In Round 1, participants from 3 stakeholder groups (experts, policy‐makers and families) rated a list of 52 potential indicator identified from a scoping review and interviews with breastfeeding mothers. Participants could also suggest additional indicators. In Round 2, participants were shown the ratings of the other participants and were asked to rate the items again with the choice of changing their original ratings. Consensus was defined as more than 70% participants rating an item as critical (score 7–9) or not important (1–3). Any item that did not reach consensus was discussed at a consensus meeting.Results: There were 107 participants from 14 countries. After both rounds, 50 (out of 56) items reached consensus. A consensus meeting with selected participants from the 3 stakeholder groups discussed items that did not reach consensus. The final list had 52 items that was summarized into 5 sectors – administration, community, healthcare, workplace and collaboration.Conclusion: Using a systematic approach, we identified a list of indicators in 5 sectors of a breastfeeding‐friendly city. The next step is to determine how each of these indicators can be measured and applied.7. What is known about cow's milk protein allergy in preterm infants?Mona Florquin1, An Eerdekens21Department of Pediatrics, University Hospital Leuven, KU Leuven, Belgium2Department of Neonatology, University Hospital Leuven, KU Leuven, BelgiumBackground: Cow's milk protein allergy (CMPA) is well described in term infants, as opposed to preterm infants. In preterm infants, CMPA shares many gastro‐intestinal symptoms with necrotizing enterocolitis (NEC).Objectives: To evaluate the presentation of CMPA in preterm infants and to investigate the different diagnostic and therapeutic options.Methods: We searched for relevant literature using the medical databases PubMed, Web of Science, and the Cochrane Library. We performed a post hoc analysis on the 25 case‐reports included in this study.Results: Literature was scarce and heterogeneous. The majority of preterm infants with CMPA were exposed to bovine‐based milk proteins prior to the development of symptoms. The most common clinical manifestations were bloody stools, vomiting and abdominal distension. Of the 25 cases, only seven (28%) retained human milk in their diet after diagnosis. In the larger studies, no study has human milk as primary feeding choice after diagnosis.Conclusions: Preterm infants exposed to a type of cow's milk‐based formula in their first days of life, have a higher risk of developing CMPA. Most of the preterm infants are no longer fed with human milk after the diagnosis of CMPA is made, which is in contrast with current feeding guidelines. We strongly advocate that human milk with mothers on a cow's milk free diet is the first choice of feed after the diagnosis of CMPA. Prospective studies are necessary to obtain more information regarding clinical presentation, diagnostic tools and therapeutic approaches.8. Facility‐based maternal and newborn care during the COVID‐19 pandemic: IMAgiNE EURO Study findings on breastfeeding practices in 12 countriesMarzia Lazzerini,1 Benedetta Covi,1 Ilaria Mariani,1 Zalka Drglin,2 Maryse Arendt,3 Ingvild Hersoug Nedberg,4 Helen Elden,5,6 Raquel Costa,7,8,9 Daniela Drandić,10 Jelena Radetić,11 Marina Ruxandra Otelea,12,13 Céline Miani,14 Serena Brigidi,15 Virginie Rozée,16 Barbara Mihevc Ponikvar,2 Barbara Tasch,3,17 Sigrun Kongslien,18 Karolina Linden,5 Catarina Barata,19 Magdalena Kurbanović,20 Jovana Ružičić,11 Stephanie Batram‐Zantvoort,14 Lara Martín Castañeda,21 Elise de La Rochebrochard,16 Anja Bohinec,2 Eline Skirnisdottir Vik,22 Mehreen Zaigham,23 Teresa Santos,24,25 Lisa Wandschneider,14 Ana Canales Viver,26 Amira Ćerimagić,27 Emma Sacks,28 Emanuelle Pessa Valente11WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy2National Institute of Public Health, Ljubljana, Slovenia3Beruffsverband vun de Laktatiounsberoderinnen zu Lëtzebuerg asbl (Professional association of the Lactation Consultants in Luxembourg), Luxembourg, Luxembourg4Department of community medicine, UiT The Arctic University of Norway5Institute of Health and Care sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden6Region Västra Götaland, Sahlgrenska university hospital, Dept of Obstetrics & Gynecology, Gothenburg, Sweden7EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal8Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal9Human‐Environment Interaction Laboratory, Universidade Lusófona, Portugal10Roda – Parents in Action, Zagreb, Croatia11Centar za mame, Belgrade, Serbia12University of Medicine and Pharmacy Carol Davila, Bucharest, Romania13SAMAS Association, Bucharest, Romania14Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany15Department of Anthropology, Philosophy and Social Work. Medical Anthropology Research Center (MARC). Rovira i Virgili University (URV), Tarragona, Spain16Sexual and Reproductive Health and Rights Research Unit, Institut National d'Études Démographiques (INED), Paris, France17Neonatal intensive care unit, KannerKlinik, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg18Department of health and care sciences, UiT The Arctic University of Norway19Institute of Social Sciences of the University of Lisbon, Lisbon, Portugal20Faculty of Health Studies, University of Rijeka, Rijeka, Croatia21Institut Català de la Salut, Generalitat de Catalunya, Spain22Department of health and caring sciences, Western Norway University of Applied Sciences, Norway23Obstetrics and Gynaecology, Department of Obstetrics and Gynecology, Institution of Clinical Sciences Lund, Lund University, Lund and Skåne University Hospital, Malmö, Sweden24Centro de Investigação Interdisciplinar em Saúde (CIIS) da Universidade Católica Portuguesa, Lisbon, Portugal25Universidade Europeia, Lisboa, Portugal26Institut Català d'Antropologia (ICA), Barcelona, Spain27NGO Baby Steps, Sarajevo, Bosnia‐HerzegovinaBackground: Evidence suggests poor quality of maternal and newborn care (QMNC) during the COVID‐19 pandemic. Few studies have investigated quality of breastfeeding practices utilising the WHO Standards as a reference, and using the same set of indicators across several countries.Objectives: Investigate the WHO Quality Measures related to breastfeeding practices during the COVID‐19 pandemic, in 12 countries of the WHO European Region.Methods: Data were collected via IMAgiNE EURO, a multi‐country, cross‐sectional study using an anonymous, online questionnaire including 40 WHO Standard‐based Quality Measures. Women who gave birth in health facilities in the WHO European Region from March 2020 to March 2021 were eligible.Results: Overall, 21027 mothers were included, of whom 85.9% (18063) underwent labour. Major heterogeneity was found across countries in breastfeeding practices: lack of skin‐to‐skin ranged from 0.5% in Luxemburg to 64.4% in Romania; lack of early breastfeeding, inadequate breastfeeding support, lack of rooming‐in were consistently higher in Serbia (69.9%, 56.9%, 55.6% respectively) and lower in Luxemburg (4.7%, 16.5%, 5.5% respectively) compared to other countries. Lack of exclusive breastfeeding at discharge ranged from 17.5% in Spain to 44.1% in Romania. Women who had a prelabour caesarean section reported gaps in breastfeeding practices more frequently than women who had experienced labour (p < 0.02).Conclusion: Large inequities exist across countries in the WHO European Region in the quality of breastfeeding‐related practices. Multi‐level actions are urgently needed to promote breastfeeding and enhance support to women during and beyond the COVID‐19 pandemic.9. Breastfeeding experiences during hospitalization for childbirth among migrant versus non‐migrant women: preliminary results of the IMAgiNE study in ItalyEmanuelle Pessa Valente1, Ilaria Mariani1, Karen Loisotto2, Gina Cervi2, Marzia Lazzerini11Institute for Maternal and Child Health ‐ IRCCS “Burlo Garofolo” ‐ WHO Collaborating Centre for Maternal and Child Health, Trieste, Italy2Trieste University, Department of Medicine, Surgery and Health Sciences, Trieste, ItalyBackground: Evidence suggests gaps in the quality of maternal and newborn care during childbirth in Italy. Migrant population is particularly vulnerable. Few studies have investigated migrant women’ perspectives, in particular when related to breastfeeding experiences, using the WHO Standards as reference.Objectives: The study aimed at investigating breastfeeding experience during hospitalization for childbirth, in migrant versus non‐migrant women, in Friuli Venezia‐Giulia (FVG) region, North‐East Italy.Methods: Cross‐sectional study using validated, anonymous, telephone interview based on WHO Standards. Women given birth in one of the nine maternity hospitals of FVG region, in the period from September 2019 – April 2022 were eligible to participate. We compared indicators related to breastfeeding experience among migrant versus non‐migrant women using a Chi‐square test. Values p < 0.05 indicate statistical significance.Results: A total of 4882 women were included, of whom 883 (18.1%) migrants (Table 1). We found no statistically significant differences between migrant and non‐migrant women reports of skin to skin (86.2% migrants vs 86.6%, p = 0.757), breastfeeding support from health workers in the first hour after birth (76.3% migrants vs 75.0% non‐migrant, p = 0.404) and rooming‐in (87.1% migrants vs 86.5% non‐migrant, p = 0.654). Overall, exclusive breastfeeding rate at discharge had a large heterogeneity across maternity hospitals, with higher rates reported by migrant women (86.1% migrants vs 78.4% non‐migrant, p < 0.001).Conclusion: Actions are needed to ensure breastfeeding promotion across facilities and high‐quality care to all women and newborns.10. A neural window on a primitive relationship: the cerebral synchronization between mothers and their newborns during breastfeedingStefano Bembich, Elena Castelpietra, Jenny Bua, Enrica Causin, Chiara Pavan, Laura TravanInstitute for Maternal and Child Health IRCCS “Burlo Garofolo” – Trieste, Italy for all authorsBackground: Early co‐regulation processes between mothers and newborns involved in the primary relationship have been described and breastfeeding is part of it. A reciprocal co‐regulation involving their brain may be hypothesized too.Objectives: This research aimed to identify a possible synchronization between mother and newborn's cerebral cortex functional activation during breastfeeding.Methods: Twenty mother‐full term newborn dyads were enrolled. Cortical activation during breastfeeding was identified by multichannel near‐infrared spectroscopy, which detects changes in haemoglobins concentration from multiple regions of the cortex. Functional activity was simultaneously detected (hyperscanning) in mothers and their newborns' frontal cortex. The first five minutes of breastfeeding were monitored and oxygenated haemoglobin increase was identified as a cortical activation estimate. Wavelet Transform Coherence (WTC) analysis was used to identify a possible synchronization between functional activations in mother and newborn's frontal cortex.Results: Newborns showed a functional activation in right somatosensory/primary motor cortex and mothers in central somatosensory/primary motor cortex. WTC analysis revealed a cyclic functional synchronization between the cortical regions found activated in mothers and newborns.Conclusion: During breastfeeding, newborns show an activation of the right somatosensory/primary motor cortex and mothers of the central somatosensory/primary motor cortex. Breastfeeding seems to be associated with an intense experience for both newborns and mothers. Moreover, the frontal cortex of both partners shows to be cyclically synchronized throughout the first five minutes of breastfeeding, revealing a common sharing of experiences associated with somatosensation, reciprocal dynamic motor adjustment and attachment related feelings, which permeates the primary dyad during such a primitive experience.11. Considering the Environmental Impact of Powdered Baby Formula in Planetary and Population Health PolicyKarin Cadwell, Anna Blair, Cindy Turner‐MaffeiHealthy Children Project, United StatesBackground: Breastfeeding is situated in the nexus between the health of the earth's environment and the health of its population. Although human milk feeding has negligible cost to the environment and is the undisputed foundation of optimal population health, around two‐thirds of humans are fed processed foods, such as powdered baby formula, as a substitute for human milk in the first 2 years after birth.Objective: Describe the environmental cost of powdered standard infant, special, follow‐on and growing‐up formula data as has been calculated for more than a dozen countries including those in the Asia Pacific region, North America, South America and Europe.Method: Compare the differences in computations of the minimal estimate of greenhouse gas (GHG) “farm to gate” emissions for powdered baby formula products sold in different parts of the world.Results: Powdered infant formula is a highly processed food that contributes GHG emission for a kilogram of milk formula (including standard infant formula, follow on formula, and toddler milk), from a low of around 4 kg CO2 eq. in Asia Pacific countries to a high of more than 10 kg CO2 eq. for “growing up” powdered formula in North America.Conclusion: Along with the acknowledged health and social benefits of breastfeeding, the cost to the environment should be considered in developing and funding infant feeding policies and supportive practices.12. Breastfeeding mothers undergoing a (surgical) procedure: health care providers' advice and experienced practices by mothersJoke Muyldermans1, Santina Gorsen2, Kristien De Paepe2, Eline Tommelein11Faculty of Medicine and Pharmacy, Department of Pharmacy, Vrije Universiteit Brussel, Jette, Belgium2Faculty of Medicine and Pharmacy, Department of Pharmacy, In Vitro Toxicology and Dermato‐Cosmetology, Vrije Universiteit Brussel, Jette, BelgiumBackground: Multiple recommendations are published considering breastfeeding mothers who need to undergo a (surgical) procedure to support and protect the continuation of breastfeeding.Objectives: To map advice of health care providers (HCPs) and experiences of breastfeeding women concerning undergoing a (surgical) procedure during breastfeeding.Methods: This cross‐sectional study ran from February 2021 to April 2022 assessing advice of HCPs and experiences of mothers through online questionnaires. HCPs could participate when they came into contact with breastfeeding mothers at least once a year. A mother could participate when she was living in Belgium, older than 18 year and underwent a (minor or major) (surgical) procedure during breastfeeding in the 2 preceding years. Participants were reached through social media channels, HCP professional organization and HCPs (for mothers).Results: Questionnaires were completed by 291 HCPs and 183 mothers. HCPs believed their knowledge about breastfeeding to be good and almost all acknowledged the superiority of breastfeeding and the importance of its continuation after surgery. However, very few HCPs are familiar with published protocols. Each recommended practice is routinely advised by less than half of HCPs. The parallel research in breastfeeding mothers confirmed that each recommended practice was given to less than 40% of mothers. For a quarter of the respondents, the use of medication during surgery was never discussed and more than 70% of mothers received no or incorrect advice about breast milk storage or use.Conclusion: There is a knowledge gap leading to inappropriate care for breastfeeding mothers undergoing a (surgical) procedure.Poster Session13. How accepted is public breastfeeding in Germany? Experiences and Attitudes of the Population and Breastfeeding Mothers 2016 and 2020Stephanie Luecke1, Severine Koch2, Gaby‐Fleur Boel2, Maria Flothkoetter11Healthy Start ‐ Young Family Network, Federal Centre for Nutrition, Bonn, Germany2Department Risk Communication, German Federal Institute for Risk Assessment, Berlin, GermanyBackground: Germany is only moderately breastfeeding‐friendly. Based on a reference study, a survey on the acceptance of breastfeeding in public was conducted.Objectives: The aim of the work is to capture perceptions and attitudes towards public breastfeeding in comparison between 2016 and 2020. In addition, differences between the general population and mothers of young children as well as between mothers with different levels of education are considered.Methods: 1,007 people aged 16 and older and 307 mothers with children up to 24 months were surveyed online about public breastfeeding in 2020.Results: In 2020, a larger percentage of mothers breastfeed in public than in 2016. Mothers with lower levels of education are less likely to breastfeed, also in public, and more likely to report mixed reactions. Among the general population, acceptance of public breastfeeding has declined. The potential for conflict noted in 2016, e.g., in restaurants, has intensified. About one in six (17%) explicitly rejects breastfeeding in public. Knowledge about the health effects of breastfeeding is lower among the general public than among mothers. As in 2016, knowledge about the positive effects of breastfeeding is associated with greater acceptance of public breastfeeding.Conclusion: The results underline the importance of measures that increase the acceptance of breastfeeding, for example, to communicate knowledge to the population, to show breastfeeding more frequently in mass media and through positive role models, and to make the settings in which families live more breastfeeding‐friendly. Measures should pay special attention

Comparison of commercial allergen extract with various milk products of skin prick tests in diagnosing cow's milk protein allergy

Introduction: In this study, we aimed to solve the incompatibilities between the skin prick test (SPT) result and the clinical picture encountered among patients. Thus, we used various milk products (raw, ultrahigh temperature [UHT], and pasteurized cow's milk) with commercial milk allergen extract in patients we think may have cow's milk protein allergy (CMPA) and made a comparison among the milk types. Methods: This study was conducted retrospectively between February 1, 2019, to June 1, 2019, at a pediatric allergy polyclinic of the university training/research hospital. A pair of 79 individuals, as control and patient groups, ages between 1 month and 21 years who were presented with a suspicion of CMPA and defined with SPT and/or allergen-specific immunoglobulin E (IgE) levels were included in the study. Allergen-specific IgE tests (specific IgE cow's milk, β-lactoglobulin, α-lactalbumin, casein) were evaluated. SPT was performed with fresh/raw, UHT, and pasteurized (daily) cow's milk besides the standard used commercial extract. Results: In the group included in the study and defined as IgE-mediated CMPA, 52.9% of the 79 patients were boys (n = 46), 47.1% were girls (n = 33), and the median age was 6 months (5.0-8.0 months). In the group of specific IgE cow's milk reaction that was sought, frequency and wheal (induration) size of SPT reaction to fresh/raw milk was also found to be statistically significant between positive- and negative-reaction groups, not detected against other milk products. The area under the curve for the diagnostic value of fresh milk was 93.1%. For the cutoff value of 2.50 mm, 88.1% sensitivity and 90.8% specificity were determined. In the group of specific IgE β-lactoglobulin reaction searched, there was a statistically significant difference in the frequency of SPT positivity and wheal size against UHT, fresh, and daily/pasteurized milk between positive and negative reaction groups. When the correlations of the mean induration axis in the tests were examined, it was found that, among raw milk, daily milk, cow's milk allergen extract, and UHT milk, a strong positive correlation was also statistically significant. Conclusion: The positivity that could not be detected with SPT when using allergen extract in a patient with positive specific IgE cow's milk result in the clinic can be detected with SPT made with fresh (raw) milk, which can be an alternative. In addition, specific IgE β-lactoglobulin seems to be the most compatible with the SPT wheal size (induration) of other milk types rather than extract. Comparative studies of SPT allergen extracts and various milk types used in the diagnosis of CMPA are very scarce in the literature, and more studies are needed on this subject.

Awareness or neglecting the diagnosis of cow milk protein allergy in the neonatal period.

Cow milk protein allergy (CMPA) can mimic surgical disease, gastroenteritis, sepsis, and necrotizing enterocolitis in the neonatal period. For this reason, we aimed to evaluate the clinical features, differential diagnosis, and treatment methods of neonates with CMPA. The charts of twenty-six breastfed full-term and preterm newborns presenting with CMPA between October 2018 and February 2021 were retrospectively reviewed. The clinical symptoms, laboratory findings, and methods used in diagnosis and treatment were analyzed. CMPA was diagnosed in preterm infants 50% (n=13) at the same rate as in full-term infants 50% (n=13) between 32 to 38 weeks corrected age (median 36 weeks). Among patients with CMPA, 69.2% (n=18) had blood in the stool at the onset. Cow's Milk-related Symptom Score score was found to be significantly higher prior to diagnosis vs. after treatment with the cow milk protein-free mom's milk diet [12(11-13) vs. 4(3-5), p<0.001]. Seventy-two hours after the commencement of the mothers' elimination diet, macroscopic blood in stool disappeared in all patients except one patient. Oral food challenge (OFC) for the diagnosis of CMPA was carried out on all (n=26) neonates. Eosinophilia was seen in 46.2% of patients (n=12). The methemoglobin concentration was 1.1 to 1.5% (median 1.3%). CMPA should be kept in mind for well-appearing preterm and full-term infants suspected of necrotizing enterocolitis and gastroenteritis, respectively, presenting with bloody stool and eosinophilia. The use of OFC can be implemented since neonates were very well monitored in the neonatal intensive care unit. Treatment is possible by continuing breastfeeding.

Body growth assessment in children with IgE-mediated cow's milk protein allergy fed with a new amino acid-based formula.

BackgroundAmino acid-based formula (AAF) is a relevant dietary option for non-breastfed children. The present study was designed to evaluate the body growth pattern in cow's milk protein allergy (CMPA) children treated for 6 months with a new AAF.MethodsThis was an open-label, single arm study evaluating body growth pattern in immunoglobulin E (IgE)-mediated CMPA infants receiving a new AAF for 6 months. The outcomes were anthropometry (weight, length, head circumference), adherence to the study formula and occurrence of adverse events (AEs).ResultsFifteen children [all Caucasian and born at term; 53.3% born with spontaneous delivery; 80% male; 80% with familial allergy risk; mean age (±SD) 3 ± 2.5 months at IgE-mediated CMPA diagnosis; mean age (±SD) 16.7 ± 5.9 months at enrolment, mean total serum IgE (±SD) 298.2 ± 200.4 kU/L] were included and completed the 6-month study. Data from fifteen age- and sex-matched healthy controls were also adopted as comparison. At baseline, all CMPA patients were weaned and were receiving the new AAF. All 15 patients completed the 6-month study period. For the entire CMPA pediatric patients’ cohort, from baseline to the end of the study period, the body growth pattern resulted within the normal range of World Health Organization (WHO) growth references and resulted similar to healthy controls anthropometric values. The formula was well tolerated. The adherence was optimal and no AEs related to AAF use were reported.ConclusionsThe new AAF ensured normal growth in subjects affected by IgE-mediated CMPA. This formula constitutes another suitable safe option for the management of pediatric patients affected by CMPA.

Fecal calprotectin levels in pediatric cow's milk protein allergy.

IntroductionThe most prevalent food allergy in younger children is cow's milk protein allergy (CMPA), a hypersensitivity reaction to cow's milk protein and its most common clinical manifestation is allergic colitis. The goal of our recent study was to assess somatic symptoms of CMPA and to prospectively observe the effects of a dairy elimination diet using objective parameters and questionnaires.MethodsThe County Hospital in Szekszárd, Hungary, investigated children aged 1 to 18 who had clinical signs that might indicate CMPA. Stool samples were taken and analyzed using a fecal calprotectin (FC) rapid test (Quantum Blue fCAL, Bühlmann Laboratories, Switzerland) at the time of the diagnosis and following 3 months of an elimination diet. At the baseline visit as well as the first and second follow-up, questionnaires were filled out. Patients were divided into two subgroups according to dietary guidelines based on the results of the questionnaires.ResultsA total of 47 patients participated in the study [42.55% female, mean age: 7.36 (SD 4.22) years]. There was no significant difference in FC levels between baseline and after 3-month elimination diet [73.98 (71.12) μg/g and 68.11 (74.4) μg/g, respectively, p = 0.331]. After three months, there was a significant decrease in FC levels among patients who adhered to the strict diet [84.06 (79.48) μg/g and 41.11 (34.24) μg/g, respectively, p = 0.001].ConclusionThe findings of our study suggest that FC can be an objective marker in confirming the diagnosis of CMPA. Significant improvement in clinical symptoms and in FC levels can only be expected after a strictly followed elimination diet.

Assessment of the Cow’s Milk-related Symptom Score (CoMiSS) as a diagnostic tool for cow’s milk protein allergy: a prospective, multicentre study in China (MOSAIC study)

ObjectivesThe MOSAIC study aimed to evaluate if the Cow’s Milk-related Symptom Score (CoMiSS) can be used as a stand-alone diagnostic tool for cow’s milk protein allergy (CMPA).DesignSingle-blinded, prospective, multicentre diagnostic...

Feeding practices and the prevalence of cow's milk protein allergy in Irish preterm infants.

The prevalence of cow's-milk protein allergy (CMPA) is between 2% and 3% and symptoms vary depending on underlying immune mechanism at play. Breast milk is the optimal nutrition for premature infants and breast milk fortifiers (BMF) are commonly used to optimise growth and nutrition. BMF are typically derived from cow's milk and, as such, preterm infants are exposed to cow's milk in the first weeks of life. Previously, preterm infants were suspected to have a higher risk of allergen development because of early antigen exposure and increased gut permeability. The primary aim of the present study was to evaluate the prevalence of CMPA among very preterm (<32 weeks) and/or very low birth weight (VLBW) infants. The secondary aim was to describe feeding practices, specifically the breastfeeding rates and specialist, non-standard formula use in this cohort over the first 6 months of life. This was a retrospective study performed in a large tertiary maternity hospital (8500 deliveries/year and 110 very preterm infants/year) in Dublin, Ireland over a 3-year period, 2017-2020. Infants born very preterm and/or VLBW who were followed in the outpatient clinic until 6 months corrected gestational age (CGA) were included. Hospital ethical approval was obtained. One hundred and forty-four infants were included with a median birth weight of 1338 g. No infant had a diagnosis of CMPA when leaving the neonatal intensive care unit (NICU) but, by 6 months CGA, this increased to 1.4% (n = 2). Upon discharge from the NICU, 88 infants (61%) were receiving at least some breast milk, decreasing to 13 (9.1%) at 6 months CGA. Those who were receiving exclusive breast milk at discharge were significantly more likely to still be receiving any breast milk at three (p ≤ 0.001) and 6 months ( p ≤ 0.001) CGA compared to those combined feeding or exclusively formula feeding. At 6 months CGA, 18.9% (n = 27) were attending a dietician and 31.5% (n = 45) were using specialist, non-standard infant formula. The prevalence of CMPA in this cohort was 1.4%, which is similar to the reported prevalence of CMPA in the general paediatric population. Infants who were discharged from NICU exclusively breastfeeding were more likely to be receiving any breast milk at outpatient follow-up. This highlights the importance of on going dietetic and lactation support in the outpatient setting for this vulnerable cohort.

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.

Assessment of CoMiSS among Children with Cow's Milk Allergy at Zagazig University Hospital

Background: Cow’s milk protein allergy (CMPA): The topic of definition still causes confusion among physicians. Words such as “allergy,” “intolerance,” and “hypersensitivity” are used interchangeably. The accepted definition of allergy is “a hypersensitivity reaction triggered by specific immunologic mechanisms”. There is no such thing as “allergy to lactose” but rather lactose intolerance. The authors introduced the acronym “CoMiSS” (cow’s milk-related symptom score). Objective: To evaluate CoMiSS in children with cow's milk allergy at Pediatric Department, Faculty of Medicine, Zagazig University. Patients and Methods: This study was conducted during the period from December 2018 to May 2020.  Cow’s milk-related symptom score was assessed. Results:  There was statistically significant increase in eosinophilic count among confirmed CMA than no CMA. There was statistically significant higher total score of CoMiSS among confirmed CMA than no CMA, and another one regarding each symptom of CoMiSS score. Accuracy of CoMiSS in diagnosis of CMA was 90.8%. The percentage was for sensitivity (86.4%), specificity (93.4%), positive predictive value (88.3%) when the score is >12 and negative predictive value (92.2%). Conclusion: CoMiSS is a simple, fast, and easy-to-use tool to raise awareness and help in early diagnosis of CMPA, but hard to handle with many of illiterate mothers. CoMiSS is a helpful tool and applicable method to screen for CMPA, though there may be risk of under-diagnosis when CoMiSS≥12 is used as the criterion for early pick-up of CMPA in Egyptian infants.

Evaluation of Skin Prick Test and Specific Immunoglobulin E for Diagnosis of Infants with Cow’s Milk Protein Allergy

Cow’s Milk protein allergy (CMA) is a common finding in infants and young children (2-3%). Its diagnosis is a multifaceted aspect including medical history, clinical examination, diagnostic elimination diets, oral challenge tests (OCT), skin prick tests (SPTs) and specific immunoglobulin E (sIgE) measurements. We aimed to assess the value of SPT and sIgE for diagnosis of infants with CMA in routine clinical practice. This cross sectional study included 102 infants with suspected CMA. They were subjected to OCT, SPT with pasteurized cow's milk and measurement of serum sIgE for cow’s milk by immunoblot technique. Seventy-two infants (70.59%) showed positive allergic reactions with OCT. Comparing SPT to OCT, sensitivity was 75%, specificity was 68.7%, predictive value for negative (PVN) was 59% and predictive value for positive (PVP) was 93.1%. Comparing sIgE to OCT, sensitivity was 68.1%, specificity was 96.7%, PVN was 69% and PVP was 98%. Comparing both SPT and sIgE together to OCT, sensitivity was 62.5%, specificity was 96.6%, PVN was 51.8% and PVP was 97.8%. For clinical practice, our findings suggest that correlation between SPT and sIgE is significant regarding CMA diagnosis. Therefore, these tests can be used together for diagnosis of CMA. However, still some cases can be only diagnosed with positive OCT with non-detectable sensitization. Therefore, a detailed history is a major factor in assessing CMA. In addition, definition of new optimal cut-offs for sIgE and SPT to cow’s milk can improve the accuracy of these tests, hoping to avoid unnecessary and potentially dangerous OTC.

A Trial of an Anamnesis-based Score Applied as a Diagnostic Tool for Cow's Milk Protein Allergy in Children.

This study presents an anamnesis-based questionnaire as a diagnostic tool for cow's milk protein allergy (CMPA) in children. We applied 24 dichotomous yes/no questions to 51 cases diagnosed by oral challenge and 31 controls. All patients were recruited at the pediatric gastroenterologist outpatient practice. Patients with CMPA presented with a family history of atopy/autoimmunity, cesarean delivery, use and/or change of formulas, use of antacids/antibiotics in the first 6 months of life, an overly clean caregiver, multisystem clinical presentation, and the absence of seasonal symptoms. The CMPA group had an average score of 10.4 versus 3.2 for the control group. We identified a cut-off score of 7, which had 94.4% sensitivity and 96.9% specificity to distinguish CMPA from the control population. Cases were younger and showed different symptoms than controls. This study shows the usefulness of an anamnesis-based clinical score to guide the diagnosis of CMPA in children.

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.

Alergia a la proteína de leche de vaca. Enfoque diagnóstico y terapéutico

La prevalencia de la alergia a las proteínas de la leche de vaca (APLV) en el ámbito mundial es, aproximadamente, de 1,9 a 4,9 %. En Colombia, esta cifra se desconoce. En un alto porcentaje de los casos, no existe la sospecha por parte del personal de salud, y, por lo tanto, el diagnóstico y el tratamiento se retrasan. Esto acarrea un aumento en el tiempo y en los recursos que emplean los profesionales de la salud y los padres en procura de establecer la etiología del padecimiento de los niños que presentan esta enfermedad. Dentro de este contexto, la historia clínica es fundamental en la sospecha de la APLV, y es especialmente relevante la evaluación de antecedentes, en los cuales se destacan la presencia de la exposición temprana a la proteína, así como la atopia en familiares en primer grado de consanguinidad. La presentación de la APLV puede manifestarse con reacciones inmediatas a nivel digestivo (vómitos, diarrea aguda), cutáneo (urticaria, dermatitis, angioedema) y, con menos frecuencia, a partir de signos respiratorias y sistémicos. Sin embargo, la amplia variedad de manifestaciones clínicas y signos puede ser un reto para el profesional que no se encuentre sensibilizado con la patología, e incluso soslayar este diagnóstico retrasa la suspensión de la proteína de la leche de vaca de la dieta y demora el acceso a un tratamiento eficaz. El tratamiento ideal reconocido es la dieta de exclusión, la cual requiere un estricto cumplimiento. En los niños alimentados con lactancia materna exclusiva, será necesaria la dieta restrictiva de leche y sus derivados en la madre. En quienes no reciben lactancia, se deberá tratar mediante fórmulas de proteínas lácteas extensamente hidrolizadas (FEH) o a base de aminoácidos (FAA). Así bien, el pronóstico es favorable y la mayoría de niños tolerarán las proteínas de la leche de vaca a los 2 años, mientras que en pacientes con polisensibilización el proceso puede prolongarse. En el caso de no alcanzar la tolerancia, la inmunoterapia oral es una opción disponible.

Is there an association between vitamin D levels and cow's milk protein allergy at infancy?

Food allergy is an important public health concern with an increasing prevalence. The objectives were to determine the possible association between cow's milk protein allergy (CMPA) and 25(OH)D (vitamin-D) levels of infants with an initial diagnosis of CMPA and the association between 25(OH)D levels and (a) SPT (skin prick test) induration size, (b) specific IgE to milk, (c) specific IgE to casein. Prospective, observational, case control study; the study group was composed of children < 2 years of age with a diagnosis of CMPA confirmed by an oral food challenge test. Healthy infants were enrolled as controls. Serum 25(OH) D levels were obtained at the initial workup in both groups. The correlation of vitamin-D levels was investigated in the development of CMPA. Among the study group of patients (n:56) 41,1% (n:23) had IgE-mediated and 58,9% (n:33) had non-IgE-mediated allergies There were no statistically significant differences between the CMPA and control groups (n: 55), in terms of serum 25(OH)D levels (33.85 ± 16.18ng/ml, 30.70 ± 14.90ng/ml; respectively, p:0.289). No statistically significant difference was found between study and controls according to 25(OH) D levels (adequate, insufficiency, deficiency; p=0.099). In the SPT of the CMPA group, a negative weak correlation without statistical significance was determined between the induration diameter of milk antigen and serum levels of 25(OH)D (p:0,794; r= -0,037). No significant difference was found in serum 25 (OH)D levels between infants with CMPA and healthy controls. Our results do not support the routine request for 25(OH)D levels in pediatric age CMPA patients at their initial workup.

Influence of Atopic Dermatitis on Cow's Milk Allergy in Children.

Background and Objectives: Cow’s milk protein allergy (CMA) is the most common allergy in children. The natural history of CMA is generally favorable and the majority of children reach tolerance during childhood, even if studies show variable results. Atopic dermatitis (AD) is a complex disease from an immunological point of view. It is characterized by an impaired skin barrier function and is often the first clinical manifestation of the so-called “atopic march”. The aim of our study is to evaluate, in a cohort of children with CMA, if the presence of AD in the first months of life can influence the atopic status of patients, the tolerance acquisition to cow’s milk, the level of specific IgE (sIgE), and the sensitization towards food and/or inhalant allergens. Materials and Methods: We enrolled 100 children with a diagnosis of CMA referred to our Pediatric Allergology Unit, aged 1–24 months at the time of the first visit. Results: 71 children had AD and 29 did not. The mean follow-up was 5.28 years. The CMA manifestations were mainly cutaneous, especially in children with AD (91.6% vs. 51.7%; P < 0.001). Patients with AD showed higher rates of polysensitization to foods and higher levels of both total IgE and sIgE for milk, casein, wheat, peanuts, and cat dander at different ages when compared to patients without AD. We analyzed the presence of IgE sensitization for the main foods and inhalants at various ages in the two groups of patients: a statistically significant difference emerged in the two groups of patients for milk, yolk and egg white, hazelnut, peanuts, soybean, grass pollen and cat dander. Meanwhile, we did not find significant differences in terms of tolerance acquisition toward cow’s milk, which was nonetheless reached around 5 years of age in 61% of patients. The level of cow’s milk sIgE at the age of 5 years was significantly higher in the group of patients who did not acquire tolerance (38.38 vs. 5.22 kU/L; P < 0.0001). Conclusions: An early barrier deficiency appears to promote the development of allergic sensitization, but does not seem to influence the acquisition of tolerance.

Serum eosinophilic cationic protein level and hematological parameters in infants with cow's milk protein allergy

Background Various biomarkers have been investigated in the diagnosis of cow's milk protein allergy (CMPA) in infants. To our knowledge, no prior studies have evaluated serum eosinophil cationic protein (sECP), neutrophil-lymphocyte ratio (NLR), and mean platelet volume (MPV) concurrently in infants with CMPA.&#x0D; Objective To compare sECP levels, MPV, and NLR in infants with and without CMPA, as well as to investigate the suitability of these parameters as biomarkers in the diagnosis of CMPA.&#x0D; Methods Fifty-six children with CMPA were compared to 40 healthy, similar to distribution of age and sex normal infants as controls. The serum ECP levels were detected by a chemiluminescence assay. The MPV values were calculated by devices in hemogram parameters. The NLR values were obtained by dividing the neutrophil count by the lymphocyte count.&#x0D; Results The median sECP level in the CMPA group was significantly higher than in the control group (23.5 and 9.27 ng/mL, respectively; P=0.001). However, there were no significant differences between groups with regards to median MPV (8.5 and 8.6 fL, respectively; P=0.149) and median NLR (0.35 and 0.37 respectively; P=0.637). Correlation analysis of sECP level with MPV and NLR in the CMPA group revealed no significant relationships (P&gt;0.05 for both). In the Receiver-operating characteristic (ROC) curve analysis, the optimal cut-off levels to identify CMPA for sECP, MPV, and NLR were 18.4 ng/mL (60.7% sensitivity, 97.5% specificity, and AUC: 0.831), 10.05 fL (54% sensitivity, 77.5% specificity, and AUC: 0.413) and 0.97 (14.3% sensitivity, 50% specificity, and AUC: 0.528), respectively.&#x0D; Conclusions The sECP level and blood eosinophil count are significantly higher in infants with CMPA, but MPV and NLR do not differ between infants with and without CMPA. There are also no significant correlations in the CMPA group between sECP and MPV, as well as sECP and NLR. Serum ECP might be useful as a potential biomarker for diagnosing CMPA.

Cow's Milk Protein Allergy in Infancy: A Risk Factor for Functional Gastrointestinal Disorders in Children?

The role and prevalence of cow’s milk protein allergy (CMA) in functional gastrointestinal disorders remains unclear. The aim of this review is to update knowledge on the relationship between CMA and functional abdominal pain disorders (FAPDs) in children. Cochrane Database and Pubmed were searched from inception using general and specific terms for CMA and functional gastrointestinal disorders. CMA is reported as a predisposing or coexisting factor in a wide range of functional gastrointestinal disorders in infants and children. Pathogenesis of both conditions is complex and multiple mechanisms including dysmotility and hypersensitivity might contribute to the clinical manifestations. Data supporting the possible role of food allergies in the pathogenesis of FAPDs are limited. CMA may predispose to early life inflammation and visceral hypersensitivity, which in turn might manifest as FAPDs. The diagnosis of either CMA or FAPDs and distinction between them is challenging because of nonspecific and overlapping symptoms. Lack of accurate allergy tests in non-IgE (immunoglobulin E) mediated cases is also problematic. Oral food challenge, following an elimination diet, should be performed to diagnose a suspected non-IgE CMA allergy in children with FAPDs. In the management of FAPDs, an elimination diet should be considered for a limited period to verify if the symptoms improve or resolve.