Milk-free Diet Research Articles

How to reintroduce cow′s milk?

In a child that is allergic to milk, the natural next step, following the elimination diet, is the reintroduction of cow's milk. Several questions may arise. When feasible, this reintroduction has many benefits for the child and his family. However, the disease needs to be well defined by physicians and explained to parents. They need to understand that there are different types of allergy to cow's milk, specifically IgE- and non-IgE-mediated, and each of these may exhibit both a variable duration and frequently an incomplete recovery. Deciding where to first reintroduce cow's milk to a child who has previously followed a milk-free diet, whether it be at home or in a hospital, also frequently presents an issue. Following this first reintroduction, the progressive increase of milk into the diet needs to be managed properly, as not all children will go back to a normal dairy products intake. Recent studies show that most children with milk allergy tolerate products containing baked milk and that their consumption might speed up recovery. Hence, the purpose of the milk challenge in a child on a milk-free diet is becoming, even in a child still reactive to milk, the first step of gradual and individually adapted reintroduction of milk or dairy products. When reintroduction of cow's milk does not work, immunotherapy becomes an option, and this is carried out in specialized centers.

Zawartość wapnia w diecie kobiet karmiących stosujących dietę bezmleczną

The primary method of treatment for children with hypersensitivity to cow's milk protein and yet exclusively breastfed is the temporary elimination of cow milk and its products from the mother's diet. Aim of the studyAn evaluation of the calcium content in the diet of lactating women including the supply of this macroelement during using milk-free elimination diet. Materials and methodsThe examined group consisted of 43 women who were on milk-free elimination diet, breastfeeding children with hypersensitivity to cow's milk. The control group consisted of 40 mothers taking no dietary restrictions. The 3-day record method was used to estimate the level of calcium intake. ResultsThe percentage of women on a milk-free diet, who were not provided with an adequate supply of calcium was as high as 95.3%. The average daily intake of calcium from the diet in the study group was 269.95±91.11mg (27% of the recommended dietary allowance), and in the control group 717.76±359.55mg (71.78% of the recommended dietary allowance). After taking supplementation into account, the average calcium intake in the study group was 414.32±213.84mg per day (41.43% of the recommended dietary allowance), and in the control group – 781.96±362.49mg per day (78.20% of the recommended dietary allowance). In the control group, the mothers who took calcium supplements fulfilled the recommended dietary allowance in 90.01%. ConclusionThe calcium consumption by lactating women is insufficient. The women using the elimination milk-free diet require adequate supplementation of calcium.

The natural history of cow's milk allergy in north-eastern Poland

The rate of cow's milk allergy diminishes with age. There is not enough information concerning geographical trends in persistent cow's milk allergy in children. The objective of the study was to evaluate the prevalence of persistent cow's milk allergy in children previously diagnosed with IgE-mediated cow's milk allergy (CMA). Diagnosis of cow's milk allergy was established by a medical history of symptoms associated with exposure to cow's milk, positive skin prick tests with cow's milk, the presence of milk-specific IgE, and by a positive double- or single-blind placebo-controlled food challenge with milk confirmed by a positive open-controlled milk challenge. A second oral challenge was performed after at least one year of a milk-free diet and children with a positive oral milk rechallenge were diagnosed as having a persistent CMA. Two hundred ninety-one children, 2-14 years of age (mean 5.30±3.16 years, 95% CI, 5.02-5.62 years) completed the study. Persistent CMA was diagnosed in 79 patients (27.1%). Two hundred twelve children (72.9%) outgrew their allergy to cow's milk at a mean age of 5 years after an average time of 16.4±0.8 months on an elimination diet. Eighty percent of children below 3 years of age became milk tolerant. Milk-specific IgE (p=0.018) and history of paternal bronchial asthma and/or rhinitis (p=0.020) were associated with persistence of cow's milk allergy in regression analysis. An age above 3 years, as well as features of atopy, individual and familial, may be associated with a risk of delayed tolerance to milk in children.

Food allergy and anaphylaxis – 2040. Nutritional status and dietary intake in children with cow’s milk allergy

This article was originally published online on 23 April 2013 Poor different acceptance of milk-free formulas in the diet of children with allergy to cows’ milk (CMA) poses the risk of nutritional deficiencies especially calcium, vitamin D and iron and also can lead to malnutrition. Sixty children aged 2-5 years were divided into two groups: group I - 40 children with CMA, group II –20 healthy controls. In children diagnosed with allergy to cow’s milk, milk free diet was recommended. Dietary intake and nutritional status were assessed at six-monthly intervals: at the beginning of the study and after 6 and 12 months of observation. Nutritional status of children was assessed with anthropometric traits and indices (i.e. Body Mass Index) and selected biochemical parameters were performed. Despite of differences in the average concentration in the serum of children with both groups of proteins, albumin and iron, their values ranged of standards for age, as well as the assessed value of other biochemical parameters. At the beginning of the study BMI z-score of 75% of children in group I and 80% in group II ranged between -1,0 to +1,0 whereas BMI z-score in 25% of group I and 20% of group II between -2,0 and -1,0. After 12 month follow–up in 91,5 % of children of group I and 88% of group II BMI z-score was between -1,0 to +1,0 while in 8,5% of children in group I and 12% in group II between -2,0 to -1,0. Nutritional status of children with CMA assessed by body mass index, and selected biochemical tests was normal. In children during 12 month of period of the study, positive changes in dietary habits were observed.

Manifestations of food protein induced gastrointestinal allergies presenting to a single tertiary paediatric gastroenterology unit

Background Food protein induced gastrointestinal allergies are difficult to characterise due to the delayed nature of this allergy and absence of simple diagnostic tests. Diagnosis is based on an allergy focused history which can be challenging and often yields ambiguous results. We therefore set out to describe a group of children with this delayed type allergy, to provide an overview on typical profile, symptoms and management strategies.Methods This retrospective analysis was performed at Great Ormond Street Children’s Hospital. Medical notes were included from 2002 – 2009 where a documented medical diagnosis of food protein induced gastrointestinal allergies was confirmed by an elimination diet with resolution of symptoms, followed by reintroduction with reoccurrence of symptoms. Age of onset of symptoms, diagnosis, current elimination diets and food elimination at time of diagnosis and co-morbidities were collected and parents were phoned again at the time of data collection to ascertain current allergy status.Results Data from 437 children were analysis. The majority (67.7%) of children had an atopic family history and 41.5% had atopic dermatitis at an early age. The most common diagnosis included, non-IgE mediated gastrointestinal food allergy (n = 189) and allergic enterocolitis (n = 154) with symptoms of: vomiting (57.8%), back-arching and screaming (50%), constipation (44.6%), diarrhoea (81%), abdominal pain (89.9%), abdominal bloating (73.9%) and rectal bleeding (38.5%). The majority of patients were initially managed with a milk, soy, egg and wheat free diet (41.7%). At a median age of 8 years, 24.7% of children still required to eliminate some of the food allergens.Conclusions This large retrospective study on children with food induced gastrointestinal allergies highlights the variety of symptoms and treatment modalities used in these children. However, further prospective studies are required in this area of food allergy.

The estimation of efficiency of diet therapy in atopic dermatitis and food allergy in children

Background. Clinical and immunological estimation of efficiency of different special formulas in children with atopic dermatitis due to food allergy. Methods. Fifty four children with atopic dermatitis aged 0,5—3 years old were examined. Children were divided into three groups on the base of their diet therapy. The 1 st group included 15 patients on the hypoallergenic milk-free diet, the 2 nd group (18 patients) was fed by goat milk formula, and the 3 rd group (21 children) was fed by special formula with high hydrolyzed protein. The dynamics of serum levels of IgE and IgG antibodies to cow milk protein and its fractions, and dynamics of cytokine levels (IL-4, IL-5, and IL-10) were measured during different types of diet therapy. Results. The positive skin changes during diet therapy included decrease of erythema, exudation and itching, gradual regression of rash. In 3 months of therapy complete clinical remission was achieved in 10 (66,7%) children in the 1 st group, in 14 (77,8%) children in the 2 nd group and in 15 (71,7%) children in the 3 rd group. The significant decrease of levels of IgG antibodies levels to cow milk protein and its fractions in children during different elimination diets was determined. The significant decrease of levels of specific IgE antibodies to cow milk protein (p

Cow's milk protein intolerance – an uncommon but important cause of hypoalbuminaemia

The predominant cause of paediatric hypoalbuminaemia is due to renal glomerular dysfunction. Cow9s milk protein Intolerance (CMPI) is a gastrointestinal cause of hypoalbuminaemia with estimated prevalence between 1.2% to 17%. Whilst the majority of protein losing enteropathies are diagnosed following on from referral to gastroenterology, CMPI can often be readily diagnosed by simple blood and stool tests. We report 2 cases of CMPI seen over a one year period at a district general hospital which both presented with hypoalbuminaemia. Case 1: A previously well 10 month old boy presented with 3 weeks history of generalised oedema, pallor and a 3 month history of diarrhoea which coincided with weaning from breast to formula milk. Initial investigations revealed microcytic hypochromic anaemia (Hb 5.6 g/dl) and hypoalbuminamia (serum albumin: 18 g/l). Urine dipstick was negative for protienuria. Initial investigations including immunoglobulins and celiac screen were also negative. Stool for faecal elastase was normal. He was subsequently referred to a tertiary centre for further assessment including an upper GI endoscopy and biopsy which was unremarkable. Case 2: A previously well 10 month old girl who presented with history of generalised oedema over a one week period. She had started weaning one month before and there was no history of diarrhoea. She was pale with generalised oedema. Urine dipstick was negative for protienuria. Initial investigations revealed microcytic hypochromic anaemia (Hb 5.9 g/dl) and hypoalbuminaemia (serum albumin: 14 g/l). Coeliac screen was negative. IgE levels were raised to 107 KU/l. Stool for elastase was mildly elevated to 500 µg/g and for reducing substances was suggestive of malabsorption respectively. RAST for mixed food was strongly positive. In both cases a diagnosis of CMPI was made and resolution of hypoalbuminaemia was noted after starting hypoallergic formula. In case 1, the patient required protracted investigation following on from referral to gastroenterology. In contrast, the second patient was diagnosed simply by stool and blood tests. We suggest that children with non renal hypoalbuminaemia and anaemia associated with weaning can be managed in a district hospital with a trial of cow9s milk free diet, with tertiary gastroenterology referral reserved for those who fail to respond.

Diagnosis and management of cow’s milk protein allergy in infants

Cow's milk protein allergy (CMPA) is frequently suspected in infants with a variety of symptoms. A thorough history and careful clinical examination are necessary to exclude other underlying diseases and to evaluate the severity of the suspected allergy. Care should be taken to diagnose CMPA adequately to avoid an unnecessary diet. We make recommendations based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. Skin prick tests, patch tests and serum specific IgE are only indicative of CMPA. Breastfed infants have a decreased risk of developing CMPA; an elimination diet for the mother is indicated if CMPA is confirmed. If a food challenge is positive in formula fed infants, an extensively hydrolysed formula and cow's milk-free diet is recommended. If symptoms do not improve, an amino acid based formula should be considered. In severe CMPA with life-threatening symptoms, an amino-acid formula is recommended. Elimination diet by a double-blind placebo controlled food challenge is the gold standard for diagnosis. Elimination of the offending allergen from the infants' diet is the main treatment principle.

Cow's-Milk–free Diet as a Therapeutic Option in Childhood Chronic Constipation

Cow's-Milk–free Diet as a Therapeutic Option in Childhood Chronic Constipation

Capsule Endoscopy Detection of Ileal Mucosa Alterations due to Cow Milk Malabsorption in a Celiac Patient

We report a case of a 77-year-old man suffering from celiac disease admitted as an outpatient to our clinic for the persistence of bloating and diarrhea without macroscopic steatorrhea, weight loss or an increase in circulating carbohydrate antigen 19-9. An esophagogastroduodenoscopy showed H. pylori negative antral gastritis and atrophy of the duodenal mucosa and the results of a colonoscopy were normal. Abdominal contrast-enhanced computed tomography did not show any parenchymal alteration of the liver and pancreas. The patient underwent a capsule endoscopy and the examination showed the presence of villous atrophy with microerosions at the level of the medial jejunum, in the ileum, and some areas of lymphangiectasia. A repeated capsule endoscopy after starting a lactosefree diet showed the normalization of the jejunum-ileum villous atrophy. At present, the patient is in good general health and continues a gluten- and cow milk-free diet. We should be aware that celiac patients may have lactose intolerance that cause malabsorption; the transient increase of CA 19-9 in celiac patients may be due to causes other than the presence of gastrointestinal cancer; the capsule endoscopy is useful in detecting ileal mucosa abnormalities which disappear after going on gluten- and cow milk-free diet.

End point prick test: could this new test be used to predict the outcome of oral food challenge in children with cow's milk allergy?

BackgroundCow's milk allergy (CMA) is the most frequent food allergy in childhood; the trend of CMA is often characterized by a progressive improvement to achieve tolerance in the first 4 to 5 years of life.It has been observed that specific IgE (sIgE) towards cow's milk proteins decrease when the age increases.Although food allergy can be easily diagnosed, it is difficult to predict the outcome of the oral food challenge (OFC), that remains the gold standard in the diagnosis of food allergy, by allergometric tests.MethodsWe considered 44 children with CMA diagnosed through OFC who returned to our Allergy and Immunology Pediatric Department between January to December 2010 to evaluate the persistence of allergy or the achievement of tolerance.On the basis of the history, we performed both allergometric skin tests and OFC in children that were still following a milk-free diet, whereas only allergometric skin tests those that had already undergone spontaneous introduction of milk protein at home without presenting symptoms.ObjectiveThe aim of this study was to investigate the relationship between the persistence of CMA or the acquisition of tolerance and the results of the end point prick test (EPT).Results and DiscussionThe OFC with cow's milk was performed on 30 children, 4 children were excluded because of a history of severe reactions to cow's milk, and 10 because they had spontaneously already taken milk food derivates at home without problems. 16/30 (53%) children showed clinical reactions and the challenge was stopped, 14/30 (47%) did not have any reaction.Comparing the mean wheal diameter of every EPT's dilution between the group of allergic children and the tolerant ones, we obtained a significant difference (p < 0.05) for the first 4 dilutions.We have also calculated sensitivity (SE), specificity (SP), the positive predictive value (PPV) and the negative predictive value (NPV) for each EPT dilution.ConclusionsEPT is a safe and cheap test, easy to be executed and that could provide good prediction of the outcome of OFC; so it might be used to avoid OFC-induced anaphylaxis in children affected by CMA. It can also help avoiding dietetic restrictions in tolerant children who show sensitization towards cow's milk proteins.

Efficacy of Feeding Team Recommendations for Infants/Children Presenting With Signs of Milk Allergy

Caregivers have reported feeding difficulties in approximately 25% to 40% of infants/toddlers that comprise a variety of signs/symptoms, though many of these are transient and resolve without significant medical intervention. Feeding problems, however, have been reported to persist in 3% to 10% of children, resulting in the caregivers seeking professional guidance. The purpose of this study was to evaluate the effectiveness of feeding team recommendations for infants and young children presenting with signs of milk allergies. Retrospective chart reviews were conducted, with associated follow-up phone surveys. Study participants met criteria based on presenting symptoms of possible milk allergy and received recommendations of milk-free diet and/or allergy testing. A total of 85 medical records were reviewed. Of the 85, 53% (45/85) met inclusion criteria for review; however, only 46% (39/85) were available for follow-up. Of the 39 patients available for follow-up, a milk-free diet was recommended for 67% (26/39), and 69% (18/26) of these families followed through with the recommendations. Of those 18 patients who followed the recommendations, 83% (15/18) reported improvement of symptoms. Our data suggest that recommendations resulting from comprehensive feeding team evaluations of infants and children with suspected milk protein allergies can, when followed, result in improvement of patient symptoms.

Allergic proctocolitis refractory to maternal hypoallergenic diet in exclusively breast-fed infants: a clinical observation

BackgroundAllergic proctocolitis (APC) in exclusively breast-fed infants is caused by food proteins, deriving from maternal diet, transferred through lactation. In most cases a maternal cow milk-free diet leads to a prompt resolution of rectal bleeding, while in some patients a multiple food allergy can occur. The aim of this study was to assess whether the atopy patch test (APT) could be helpful to identify this subgroup of patients requiring to discontinue breast-feeding due to polisensitization. Additionally, we assessed the efficacy of an amino acid-based formula (AAF) when multiple food allergy is suspected. amino acid-based formulaMethodsWe have prospectively enrolled 14 exclusively breast-fed infants with APC refractory to maternal allergen avoidance. The diagnosis was confirmed by endoscopy with biopsies. Skin prick tests and serum specific IgE for common foods, together with APTs for common foods plus breast milk, were performed. After a 1 month therapy of an AAF all patients underwent a follow-up rectosigmoidoscopy.ResultsPrick tests and serum specific IgE were negative. APTs were positive in 100% infants, with a multiple positivity in 50%. Sensitization was found for breast milk in 100%, cow's milk (50%), soy (28%), egg (21%), rice (14%), wheat (7%). Follow-up rectosigmoidoscopy confirmed the remission of APC in all infants.ConclusionsThese data suggest that APT might become a useful tool to identify subgroups of infants with multiple gastrointestinal food allergy involving a delayed immunogenic mechanism, with the aim to avoid unnecessary maternal dietary restrictions before discontinuing breast-feeding.

The availability and cost of a milk-free diet for cow's milk protein allergy

Background: Cow's milk protein allergy (CMPA) is the most common food allergy, and adherence to a milk-free diet is essential, particularly in immunoglobulin E-mediated CMPA sufferers (Benhamou et al., 2009). No studies have looked into the practical aspects of a milk-free diet. The aim of this project was to evaluate how the availability and cost of a milk-free diet compares with that of one containing cow's milk protein. Methods: A cross-sectional survey was conducted in the London Borough of Harrow and three major superstores in an urban setting (inclusion criteria of ≥25 000 sq ft) were randomly selected. Two shopping baskets were created; basket A with commonly consumed foods (bread, biscuits, milk, packaged fruit/vegetable salads, and ready meals which contained ≥12% protein from nondairy protein sources) based on the Eatwell plate (Food Standards Agency, 2007), and basket B with their cow's milk-free alternatives. The price and number of varieties were recorded and analysed for each food group per basket. Pearson's chi-squared and Wilcoxon-rank sum tests were conducted for availability and cost of each food type in both baskets. Results: The availability of foods suitable for a CMPA diet (basket B) was lower than basket A: 74% bread, 15% biscuits, 26% milk and 25% ready meals compared to 26%, 85%, 74% and 75%, P-values of 0.001, 0.002, 0.001 and 0.005, respectively. The availability of fruit/vegetable salads was not statistically significant between the two baskets. Regarding cost, bread in basket A was found to be significantly more expensive than in basket B, whereas milk substitutes (all superstores) and ready meals (superstore 2 only) were significantly more expensive in basket B (Table 1). The cost of biscuits and fruit/vegetable salads between the two baskets was not significantly different. Table 1. Median cost of foods in standard basket A and CMPA basket B (pence/100 g) Basket Superstore 1 Superstore 2 Superstore 3 A B P A B P A B P Bread 17.3 12.5 0.001 16.4 15.3 0.001 17.1 14.9 0.008 Biscuits 25.1 24.8 0.651 24.5 12.2 0.161 27.1 21.3 0.390 Milk or substitutes 8.5 12.5 0.002 7.8 9.4 0.001 7.9 12.4 0.003 Ready meals 63.4 70.1 0.592 54.1 66.2 0.004 61.1 66.0 0.390 Fruit/vegetable salads 50.0 65.3 0.781 33.3 49.2 0.223 65.1 62.5 0.803 Discussion: A similar previous study has investigated the practical aspects of a gluten-free diet and found that this is typically more restrictive than its alternatives (Lee et al., 2007). The findings from the present study provide further evidence that specialist diets are generally more expensive and less available than an unrestricted diet. This could present a barrier to people trying to follow a special diet and might be addressed by increasing awareness of the need for milk-free products by manufacturers and retailers. Dietitians have a role to play in this and in producing CMPA resources and providing education that takes account of barriers like cost and availability. Conclusions: It can be concluded from this study that, overall, a milk-free diet is less accessible and more expensive than an unrestricted milk-containing diet.

Oral desensitization as a useful treatment in 2‐year‐old children with cow's milk allergy

Limited published evidence shows oral desensitization to be a potential intervention option for cow's milk protein (CMPs) allergy. The aim of this study was to evaluate the safety and efficacy of oral desensitization in 2-year-old children with cow's milk allergy, as a treatment alternative to elimination diet. A total of 60 children aged 24-36 months with IgE-mediated allergy to CMPs were included in this multi-center study and were randomized into two groups. Thirty children (group A: treatment group) began oral desensitization immediately, whereas the remaining 30 (group B: control group) were kept on a milk-free diet and followed-up for 1 year. After 1-year follow-up period, 90% of the children in group A had become completely tolerant vs. 23% of the children in group B. In group A, cow's milk skin reactivity and serum-specific IgE to milk and casein decreased significantly from the initial assessment, whereas group B showed no significant change after 1 year of follow-up. Twenty-four patients (80%) developed some reaction during the treatment period: 14 children developed moderate reaction (47%) and 10 mild reaction (33%). The most common manifestations were urticaria-angioedema, followed by cough. In this study, oral desensitization was found to be effective in a significant percentage of 2-year-old children with cow's milk allergy. Oral desensitization appears to be efficacious as an alternative to elimination diet in the treatment of 2-year-old children with cow's milk allergy. The side-effect profile appears acceptable but requires further study.

The anti-deamidated gliadin peptide antibodies unmask celiac disease in small children with chronic diarrhoea

Objectives To assess the usefulness of a new class of antibodies, the anti-deamidated gliadin peptides, in the diagnostic approach to children less than 2 years with suspected celiac disease. Patients and methods We investigated 40 children (median age: 16.8 months; age range: 4–24 months), with symptoms and signs of chronic enteropathy and high serum levels of conventional anti-gliadin antibodies, but normal values of anti-transglutaminase and anti-endomysial antibodies; all underwent measurement of anti-deamidated gliadin peptides serum levels, upper gastrointestinal endoscopy with biopsies and HLA typing; 40 subjects served as controls. Results In 29 patients (group A) serum levels of anti-deamidated gliadin peptides were normal and duodenal histology showed a spectrum of abnormalities ranging from mucosal inflammatory infiltrates to villous damage (in almost all cases compatible with Marsh 1-to-2 lesions). All improved on a cow's and soy milk free diet containing gluten. In 11 patients (group B) there were high serum levels of anti-deamidated gliadin peptides and histology showed features suggestive of celiac disease (Marsh 2-to-3 lesions) in all; furthermore, human leucocyte antigen typing was consistent with a celiac disease genetic pattern in all. Group B patients significantly improved on a gluten free diet containing cow's and soy milk proteins. None of the control group was anti-deamidated gliadin peptides positive. Conclusions In children younger than 2 years with signs of chronic enteropathy and normal values of classical serum markers of celiac disease, the latter can be predicted by high serum levels of anti-deamidated gliadin peptides.

Diagnosis of cow milk allergy in the gut, never an easy task

The paper by Lins et al. 1 is an important study because it highlights several key features of cow milk protein allergy. The investigators identified 66 patients who had adverse reactions to cow’s milk protein by history. These included a variety of cutaneous, gastrointestinal, and systemic complaints. Total and allergen specific serum immunoglobulin IgE levels were measured including casein, beta lactoglobulin and alpha lactalbumin. Patients were instructed to follow a cow’s milk free diet for at least 2 weeks using a soy protein based formula. After symptoms remitted, an in-hospital cow’s milk protein challenge was performed and weekly follow-up visits were continued for 4 consecutive weeks following the in-hospital challenge, during which time patients continued to consume cow milk. About half of the patients did not have a positive reaction to cow’s milk protein. In those who did, a delayed reaction was common, occurring in 77% of those testing positive. Patients relapsed as late as the third week on cow milk protein. Specific IgE levels of two subfractions of cow’s milk protein were elevated in only a very small percentage of patients testing positive by challenge. The obvious conclusion of the paper is that many children in whom symptoms are thought to be related to cow’s milk protein allergy probably have another cause for their symptoms. Other not so obvious but equally important conclusions to be remembered from the study include the observation that most cow’s milk protein allergy in infancy and early childhood is not IgE mediated. This form of allergy is characterized by delayed hypersensitivity as is nicely illustrated by the relapse in symptoms rather late in the course of challenge, up to 3 weeks. Therefore,

Cow's milk allergy in children: adherence to a therapeutic elimination diet and reintroduction of milk into the diet

The basic treatment for cow's milk allergy (CMA) is the elimination of all cow's milk proteins (CMP) from the diet. This study aimed at characterizing the diet of children with a diagnosis of CMA, to assess the degree of adherence to the elimination diet and to evaluate the factors associated with the adherence and age of recovery. From a birth cohort study, food records of 267 children diagnosed with CMA were studied to define how strictly the elimination diet was adhered to. Subsequent food records were studied to assess the age at reintroduction of milk products in the child's diet. The families adhered to the elimination diet of the child with extreme accuracy in 85% of the cases. Older and monosensitized children had more often small amounts of CMP in their diet, possibly because of the absence of nutritional information by a dietitian/nutritionist. Adherence to the diet was neither related to any other sociodemographic factor studied nor to the age at reintroduction of milk products into the diet. The therapeutic elimination diet of children diagnosed with CMA was well adhered to. Low intakes of vitamin D, calcium, and riboflavin are of concern in children who follow or have followed a cow's milk-free diet.

Cow's‐Milk–free Diet as a Therapeutic Option in Childhood Chronic Constipation

It has been reported that a number of children with constipation respond to a diet free of cow's-milk (CM) proteins, although evidence is lacking to support an immunoglobulin E-mediated mechanism. We performed an open-label crossover study comparing CM and rice milk in 69 children who fulfilled Rome III criteria for chronic constipation. Clinical, physical, and immunologic parameters of patients who responded (R) and who did not respond (NR) to a CM-free diet were compared. Thirty-five of the 69 children (51%) improved during the first CM-free diet phase, 8 of these did not develop constipation when CM was reintroduced, and 27 children (39%) developed constipation during the CM challenge and improved during the second CM-free diet phase (R group). Thirty-four children (49%) did not improve during the first CM-free diet phase (NR group). Bowel movements per week among R children significantly increased compared with NR children (R: 2.8-7.7 vs NR: 2.6-2.7) (P < 0.001). Seventy-eight percent of the children with developmental delay responded to the CM-free diet (P = 0.007). No significant statistical difference was found between the R and NR children in terms of fiber and milk consumption; atopic or allergic history; full-blood eosinophil count and percentage, and lymphocyte populations; immunoglobulins, immunoglobulin (Ig)G subclasses, total IgE; and serum-specific immunoglobulin E for CM proteins. A clear association between CM consumption and constipation has been found in more than one third of children. However, analytical parameters do not demonstrate an immunoglobulin E-mediated immunologic mechanism.

381 Conventional AGA Positivity in Children Under Two Years of Age: Celiac Disease or Food Allergy? the Role of Anti-Deamidated Gliadin Peptide Antibodies

Background: Chronic gastrointestinal symptoms in children aged less than two years often represent a clinical challenge for paediatricians, since discriminating between coeliac disease (CD) and food allergy (FA) in this age group might be quite tricky, as classical serum markers for CD, except anti-gliadin antibodies (AGA), are not uncommonly negative. Objective: The aim of our study was to assess the role of aDGP as diagnostic tool differentiating between CD and FA in children aging less than 24 months with high levels of serum AGA, when EmA and anti-tTG are negative. Methods: We investigated 40 children (median age: 16,8 months; age range: 4-24 months), with chronic gastrointestinal symptoms suggesting either CD or FA and with high serum levels of conventional AGA, with normal values of serum IgA, anti-transglutaminase (anti-tTG) and anti-endomysial (EmA) antibodies and without sensitization to the most common food antigens. All of them underwent measurement of serum levels of aDGP (IgA and IgG) and upper gastrointestinal endoscopy with duodenal biopsies; 40 controls were ageand sex-matched to these patients in order to clarify the aDGP specificity. Results: 29 patients (group A) had normal levels of aDGP; their histological features were compatible with Marsh I to III lesions and mimicked CD. However, all of them markedly improved on a cow's milk, soy and egg free diet containing gluten. After three months, these food antigens were reintroduced; subsequently, the vast majority of children (93,1%) belonging to group A experienced a clinical relapse and the return to the previous oligoantigenic diet was once more beneficial. On the other hand, 11 patients (group B) had high serum levels of aDGP (IgG positivity in all of them; IgA positivity in 9), whereas histology showed the same lesions of group A. HLA typing was obtained; haplotypes carried by children of group B were consistent with CD genetic pattern. Moreover, they significantly improved on a gluten free diet containing cow's milk, soy and egg. None of the control group (group C) was aDGP positive. Conclusions: Our data indicate that serum IgG aDGP may be of pivotal usefulness in identifying celiac patients under two years of age with chronic gastrointestinal symptoms and only conventional AGA positivity, distinguishing them from FA. Although the great clinical improvement with GFD in group B, gluten challenge will be permorfed to confirm CD diagnosis.