Aptasensors application for cow's milk allergens detection and early warning: Progress, challenge, and perspective.

Cow's milk allergy (CMA) is considered one of the most prevalent food allergies and a public health concern. Modern medical research shows that the effective way to prevent allergic reactions is to prevent allergic patients from consuming allergenic substances. Therefore, the development of rapid and accurate detection technology for milk allergens detection and early warning is critical to safeguarding those with a cow milk allergy. As the oligonucleotide sequences with high specificity and selectivity, aptamers frequently assemble with transduction elements forming multifarious aptasensors for quantitative detection owing to their high-affinity binding to the target. Current aptasensors in the field of cow's milk allergen detection in recent years are explored in this review. This review takes a look back at a few common assays, including ELISA and PCR, before presenting a clear overview of the aptamer and threshold doses. It delves into a detailed discussion of the current aptamer-based detection techniques and related theories for milk allergen identification. Last but not least, we conclude with a discussion and outlook of the advancements made in allergen detection with aptamers. We sincerely hope that there will be more extensive applications for aptasensors in the future contributing to reducing the possibility of patients suffering from adverse reactions.

Long term outcome of IgE-mediated cow's milk allergy and risk factors for persistence.

BACKGROUND: Resolution rates of IgE-mediated cow's milk allergy (IgE-CMA) by age 5 years, and risk factors for its persistence were previously described. OBJECTIVE: To extend follow-up until the end of adolescence. METHODS: An extension study of 23 of 54 patients diagnosed with IgE-CMA from a population-based study of 13,019 newborns, who remained allergic at age 5 years. Patients were examined at age 17 and their history reviewed. Resolution was determined by regular milk consumption without adverse reactions, or a negative oral food challenge (OFC). Allergy was defined by a recent objective reaction to milk and a positive skin prick test (SPT), or by sensitization ≥95% PPV to milk. Risk factors for persistence at age 17 were examined in the entire cohort. RESULTS: Of the 23 patients followed, 8/23 (35%) had spontaneous resolution, and 15 had persistent IgE-CMA. Overall, 39 (72.2%) of the 54 patients initially diagnosed with IgE-CMA had spontaneous resolution by age 17. Risk factors for IgE-CMA persistence at age 17 years included SPT >6 mm at time of diagnosis (p=0.03), no cow's milk formula feeding in the nursery (p=0.008), and wheezing on diagnostic OFC/initial reaction to milk (p=0.04). Seven patients experienced objective reactions after age 5 years. These patients had more wheezing (p=0.045) or anaphylaxis (p=0.02) on diagnostic OFC/initial reaction and more current asthma (p=0.007). CONCLUSION: Significant rate of spontaneous resolution of IgE-CMA still occurs beyond age 5 and few patients with IgE-CMA, mostly asthmatics, experience objective reactions by early adulthood. This should be considered in the treatment approach of IgE-CMA patients.

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

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

The Efficacy and Safety of Stepwise Oral Food Challenge in Children with Cow's Milk Allergy.

INTRODUCTION: Stepwise oral food challenge (OFC) tests begin with low doses of allergens and progress to full doses. We previously reported the safety and efficacy of stepwise OFC for reintroducing hen eggs. In this study, we discuss its application for cow's milk (CM) allergy. METHODS: We included 927 children (median age, 3.2 years) who underwent CM-OFC between 2017 and 2021. The target challenge dose was classified as low (<10 mL), middle (≥10 mL but <100 mL), or full. When participants reacted to the low dose, they underwent a very low-dose OFC using baked milk or <1 mL of CM. RESULTS: Positive reactions occurred in 210 cases (22.7%), including 69 anaphylactic reactions (7.4%). A lower target dose resulted in more positive OFC results (p < 0.001) and anaphylaxis (p = 0.001). The lower dose group included more children with complete elimination of CM (p < 0.001), with numerous histories of anaphylaxis induced by CM (p < 0.001), and higher levels of total IgE (p = 0.033) and CM-sIgE (p < 0.001). A multivariate analysis indicated that in the low-dose-OFC group, higher CM-sIgE levels (p = 0.034), younger age (p = 0.005), and complete elimination of CM (p = 0.002) were associated with positive OFC results. CONCLUSION: The stepwise OFC could reintroduce small amounts of CM, even in cases with high CM-sIgE levels or a history of anaphylaxis. Performing CM-OFC at younger ages, specifically from infancy, with very low doses, might facilitate the safe reintroduction of CM.

Differential Tfh cell phenotypes distinguish IgE-mediated milk allergy from eosinophilic esophagitis in children.

BACKGROUND: IgE-mediated food allergy and eosinophilic esophagitis (EoE) are diseases commonly triggered by milk. Milk-responsive CD4+ T cells producing type 2 cytokines are present in both diseases, yet the clinical manifestation of disease in milk allergy (MA) and EoE are distinct. OBJECTIVE: To identify CD4+ T cell differences between EoE and MA that may be responsible for distinct disease manifestations. METHODS: The total and milk-specific CD4+ T cell phenotype of children with milk allergy (MA), EoE (active or in remission) and controls was measured using spectral flow cytometry of peripheral blood (all groups) or esophageal biopsies (EoE and control). RESULTS: Circulating milk-responsive T cells could be identified in active (A)-EoE and MA. An increased frequency of Th2A cells was also noted in MA and EoE. In circulating T cells, type 2 cytokine production was elevated in MA, but not EoE. Within the milk-responsive Tfh subset, a dichotomy of phenotype was noted: Tfh13 cells predominated in MA, while IL-10-producing Tfh cells predominated in EoE. In the esophagus, CD4+ T cells were constitutively activated and expressed not only type 2 cytokines, but also IL-10 and IL-21 in A-EoE. There was production of IgG4 from CD38+ plasma cells in close proximity to CD4+ T cells. In vitro activation studies demonstrated that IL-10 and IL-21 elicited strong IgG4 responses in B lymphocytes, while IL-4 and IL-13 promoted IgE production. CONCLUSION: Our studies demonstrate a dichotomy of Tfh responses that may be the basis for the different clinical manifestations to milk in EoE and MA.

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update - XI - Milk supplement/replacement formulas for infants and toddlers with CMA - Systematic review.

Background: Cow's milk allergy (CMA) is the most complex and common food allergy in infants. Elimination of cow's milk from the diet and replacement with a specialized formula for infants with cow's milk allergy who cannot be breastfed is an established approach to minimize the risk of severe allergic reactions while avoiding nutritional deficiencies. Given the availability of multiple options, such as extensively hydrolyzed cow's milk-based formula (eHF-CM), aminoacid formula (AAF), hydrolyzed rice formula (HRF), and soy formula (SF), there is some uncertainty regarding which formula might represent the most suitable choice with respect to health outcomes. The addition of probiotics to a specialized formula has also been proposed as a potential approach to possibly increase the benefit. We systematically reviewed specialized formulas for infants with CMA to inform the updated World Allergy Organization (WAO) DRACMA guidelines. Objective: To systematically review and synthesize the available evidence about the use of specialized formulas for the management of individuals with CMA. Methods: We searched from inception PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the websites of selected allergy organizations, for randomized and non-randomized trials of any language investigating specialized formulas with or without probiotics. We included all studies irrespective of the language of the original publication. The last search was conducted in January 2024. We synthesized the identified evidence quantitatively or narratively as appropriate and summarized it in the evidence profiles. We conducted this review following the PRISMA, Cochrane methods, and the GRADE approach. Results: We identified 3558 records including 14 randomized trials and 7 observational studies. Very low certainty evidence suggested that in infants with IgE-mediated CMA, eHF-CM, compared with AAF, might have higher probability of outgrowing CMA (risk ratio (RR) 2.32; risk difference (RD) 25 more per 100), while showing potentially lower probability of severe vomiting (RR 0.12, 95% CI 0.02 to 0.88; RD 23 fewer per 100, 95% CI 3 to 26) and developing food protein-induced enterocolitis syndrome (FPIES) (RR 0.15, 95% CI 0.03 to 0.82; RD 34 fewer per 100, 95% CI 7 to 39). We also found, however, that eHF-CM might be inferior to AAF in supporting a physiological growth, with respect to both weight (-5.5% from baseline, 95%CI -9.5% to -1.5%) and length (-0.7 z-score change, 95%CI -1.15 to -0.25) (very low certainty). We found similar effects for eHF-CM, compared with AAF, also in non-IgE CMA. When compared with SF, eHF-CM might favor weight gain for IgE CMA infants (0.23 z-score change, 95%CI 0.01 to 0.45), and tolerance acquisition (RR 1.86, 95%CI 1.03 to 3.37; RD 27%, 95%CI 1%-74%) for non-IgE CMA (both at very low certainty of the evidence (CoE)). The comparison of eHF-CM vs. HRF, and HRF vs. SF, showed no difference in effect (very low certainty). For IgE CMA patients, low certainty evidence suggested that adding probiotics (L. rhamnosus GG, L. casei CRL431 and B. lactis Bb-12) might increase the probability of developing CMA tolerance (RR 2.47, 95%CI 1.03 to 5.93; RD 27%, 95%CI 1%-91%), and reduce the risk of severe wheezing (RR 0.12, 95%CI 0.02 to 0.95; RD -23%, 95%CI -8% to -0.4%). However, in non-IgE CMA infants, the addition of probiotics (L. rhamnosus GG) showed no significant effect, as supported by low to very low CoE. Conclusions: Currently available studies comparing eHF-CM, AAF, HRF, and SF provide very low certainty evidence about their effects in infants with IgE-mediated and non-IgE-mediated CMA. Our review revealed several limitations in the current body of evidence, primarily arising from concerns related to the quality of studies, the limited size of the participant populations and most importantly the lack of diversity and standardization in the compared interventions. It is therefore imperative for future studies to be methodologically rigorous and investigate a broader spectrum of available interventions. We encourage clinicians and researchers to review current World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines for suggestions on how to use milk replacement formulas in clinical practice and what additional research would be the most beneficial.

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

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

ß-Lactoglobulin Separation from Whey Protein: A Comprehensive Review of Isolation and Purification Techniques and Future Perspectives.

Cow milk, although rich in essential nutrients, is a well-known allergic food that can cause allergic reactions in infants and young children. ß-Lactoglobulin accounts for 10% of the total protein in milk and 50% of the whey protein, which has high nutritional value and excellent functional properties but is also the main allergen leading to milk protein allergy. Exploring the mechanism of milk allergy and selecting suitable separation and purification methods to obtain high-purity ß-Lactoglobulin is the premise of research on reducing allergenicity. In this review, the research progress in membrane technology, gel filtration chromatography, ion exchange chromatography, affinity chromatography, precipitation and aqueous 2-phase system separation for the separation and purification of milk ß-Lactoglobulin is reviewed in detail to promote the further development of milk ß-Lactoglobulin separation and purification methods and provide a new method for the development of hypoallergenic dairy products in the future. Among these methods, ion exchange chromatography and gel chromatography are widely used, precipitation is generally used as a crude purification step, and high-performance liquid chromatography and membrane technology are used for further purification to improve the purity of allergens.

Can Faecal Zonulin and Calprotectin Levels Be Used in the Diagnosis and Follow-Up in Infants with Milk Protein-Induced Allergic Proctocolitis?

OBJECTIVE: The aim of our study was to investigate whether a 1-month-long milk-free diet results in a reduction in faecal calprotectin (FC) and faecal-zonulin-related proteins (FZRP) in children with milk-protein-induced allergic proctocolitis (MPIAP). MATERIALS AND METHODS: This is a single-centre, prospective, observational cohort study involving 86 infants with MPIAP, aged 1-3 months, and 30 healthy controls of the same age. The FC and FZRP were marked using the ELISA method (IDK® Calprotectin or Zonulin ELISA Kit, Immunodiagnostik AG, Bensheim, Germany). The diagnosis of MPIAP was confirmed with an open milk challenge test. RESULTS: FFC and FZRP proved useful in evaluating MPIAP treatment with a milk-free diet, and the resolution of allergic symptoms and a significant (p = 0.0000) decrease in the concentrations of both biomarkers were observed after 4 weeks on the diet. The FC and FZRP concentrations were still higher than in the control group. A high variability of FC concentrations was found in all the study groups. An important limitation is the phenomenon of FZRP not being produced in all individuals, affecting one in five infants. CONCLUSIONS: FC and FZRP can be used to monitor the resolution of colitis in infants with MPIAP treated with a milk-free diet, indicating a slower resolution of allergic inflammation than of allergic symptoms. The diagnosis of MPIAP on the basis of FC concentrations is subject to considerable error, due to the high individual variability of this indicator. FZRP is a better parameter, but this needs further research, as these are the first determinations in infants with MPIAP.

Impacts of people at-risk of either cow milk allergies or lactose intolerance on their daily calcium intake and bone mineral density.

Background: People who are at risk of either cow milk allergies or lactose intolerance may need to avoid consuming milk and milk products, which are well-known abundant sources of calcium (Ca). This limitation in calcium intake could affect bone health. Currently, there is limited knowledge on the impact of avoiding the consumption of milk and milk products on the daily Ca intake and bone mineral density (BMD) of people at risk of cow milk allergies. This study aimed to investigate the differences between the amount of Ca intake and BMD values between people who are at risk of cow milk allergies and those who are not. Methods: A total of 80 participants were recruited, and further divided into two groups, the at-risk cow milk allergies (AR) group (n = 40) and the normal (NOR) group, using the cow milk allergies and lactose intolerance screening questionnaire. The anthropometric assessment, body composition analyses, 3-day dietary record, and bone mass density (wrist and ankle bones) measurement of all participants were collected using the dual x-ray absorptiometry (DEXA) technique to compare the differences of variables between the two groups. Results: The participants in the AR group presented a significantly lower amount of Ca intake (317 mg/day) than those in the NOR group (623 mg/day) (p < 0.05). The bone mineral density (BMD) parameters indicated that the NOR group presented significantly higher T-scores and BMD values of the wrist (T-score = -0.27 and BMD = 0.57 g/cm2) and ankle (T-score = -0.01 and BMD = 0.59 g/cm2) bones when compared with the AR group (T-score = -1.96 and BMD = 0.48 g/cm2 for the wrist bone, and T-score = -1.18 and BMD = 0.47 g/cm2 for the ankle bone) (p < 0.05). In addition, the results indicated significantly positive correlations between the amount of Ca intake and the T-scores and BMD values of both the wrist and ankle bones among all participants (p < 0.05). Conclusion: In this responding sample, participants at risk of cow milk allergies experienced a significantly negative impact on the amount of Ca intake and BMD values. Professionals in nutrition and dietetics should provide nutrition education and strategies that can enhance the Ca intake among this population to help them meet the daily Ca intake recommendation, ultimately leading to better bone health.

Prevalence and Characteristics of Accidental Ingestions Among Pediatric Food Allergy Patients.

BACKGROUND: Despite a known diagnosis of food allergy, accidental ingestions continue to occur. OBJECTIVE: To characterize accidental ingestions, including prevalence, risk factors, food allergen triggers, and severity of reactions. METHODS: A prospective monthly survey developed by the Food Allergy Consortium at Northwestern University was administered to parents of food-allergic children between April 2015 and April 2017. The monthly survey included questions on any allergic reactions experienced in the previous month. In addition, chart reviews of 100 pediatric participants from Lurie Children's Hospital of Chicago allergy clinics (typical clinical encounters) were compared with the prospective survey results. RESULTS: A total of 196 survey participants and 100 retrospective review subjects were analyzed-31.1% of participants from the surveyed cohort and 19.0% of participants from the retrospective review reported at least 1 accidental ingestion over 1 year. The rate of accidental ingestions reported in the prospective survey was high: 10% to 25% of participants each month reported an accidental ingestion, and multiple ingestions were common. Common triggers were milk, wheat, and tree nuts. In the retrospective cohort, the highest rate of accidental ingestion (25.0%) occurred for milk, followed by sesame (20.0%) and egg (18.8%). Rates of anaphylaxis after exposure were high in both the prospective and retrospective cohorts (33.1% and 16.7%, respectively). CONCLUSIONS: Accidental ingestion rates were high among food-allergic patients. Multiple exposures, especially to milk, were common. Incidence of anaphylaxis was also high, suggesting that ongoing patient education on allergen avoidance and accidental exposure is imperative.

The Cow's Milk-Related Symptom Score (CoMiSSTM) in Presumed Healthy Egyptian Infants.

BACKGROUND: The Cow's Milk-Related Symptom Score (CoMiSS) was created as an awareness tool for cow's milk-related symptoms. After different trials, a score of ≥10 was selected to raise awareness. The CoMiSS in healthy infants needs to be determined because the score does not return to 0 during a diagnostic elimination diet. This study aims to establish normal values in healthy Egyptian infants. METHODS: In this prospective cross-sectional study, pediatricians determined the CoMiSS in healthy infants ≤ 12 months. Infants seeking medical help due to cow's milk allergy (CMA) symptoms and infants with any known or suspected diseases, preterm delivery, medication, or food supplements were excluded. RESULTS: A total of 808 infants were included with a median (Q1; Q3) age of 7 (3;10) months (50.7% boys). The median (Q1; Q3) CoMiSS was 5 (5;6). The 95th percentile was 7. There was no significant difference in the median CoMiSS according to gender (p = 0.621) or due to breastfeeding exclusively (p = 0.603). A significant difference was seen in the CoMiSS according to age, although all the age categories had a median CoMiSS of 5. CONCLUSIONS: This study revealed the median CoMiSS is 5 in presumed healthy Egyptian infants aged 0-12 months. The CoMiSS was not dependent on feeding. The determination of the CoMiSS in healthy infants allows for the determination of a cut-off under which CMA is unlikely, and a cut-off to raise awareness of CMA, thereby preventing under- and overdiagnosis. Since the median CoMiSS was not different in European infants, the outcome suggests that the CoMiSS may be a reliable awareness tool for CMA independent of ethnicity. However, additional studies are needed to confirm the previous hypothesis.

Aspiration of acidified milk induces milk allergy by activating alveolar macrophages in mice.

BACKGROUND: Epidemiological studies have identified associations between gastroesophageal reflux (GER) and cow's milk allergy (CMA) in infants. However, the role of GER in the development of CMA remains poorly understood. Our primary objectives were to develop a mouse model that suggests GER as a potential pathogenic mechanism for CMA and to elucidate the immunological mechanisms that connect lung innate immunity with CMA. METHODS: Mice were exposed to cow's milk (CM) treated with hydrochloric acid through repeated aspiration into their airways. Subsequently, they were challenged by intraperitoneal injection of CM extract. The immunological mechanisms were investigated using comprehensive single-cell RNA sequencing (scRNA-seq) analysis of the lungs, combined with the use of genetically modified mice. RESULTS: Mice exposed to CM mixed with hydrochloric acid via airway sensitization developed CMA, as evidenced by the production of antigen-specific IgE and IgG antibodies, and the induction of anaphylaxis upon systemic antigen administration. In contrast, aspiration of CM alone did not induce CMA. scRNA-seq analysis revealed potential roles of alveolar macrophages in response to hydrochloric acid. Mice lacking the TLR4 pathway were protected from developing CMA. CONCLUSIONS: We have developed a novel mouse model for CMA that utilizes the natural antigen and follows the physiological airway sensitization pathway, thus potentially resembling clinical scenarios. This model, named the acidified milk aspiration-induced allergy model, has the potential to shed light on the role of early innate immunity by analyzing a more physiological model.

Specific Gut Microbiome Signatures in Children with Cow's Milk Allergy.

Although gut dysbiosis is associated with cow's milk allergy (CMA), causality remains uncertain. This study aimed to identify specific bacterial signatures that influence the development and outcome of the disease. We also investigated the effect of hypoallergenic formula (HF) consumption on the gut microbiome of milk-allergic children. 16S rRNA amplicon sequencing was applied to characterize the gut microbiome of 32 milk-allergic children aged 5-12 years and 36 age-matched healthy controls. We showed that the gut microbiome of children with CMA differed significantly from that of healthy children, regardless of whether they consumed cow's milk. Compared to that of healthy cow's milk consumers, it was depleted in Bifidobacterium, Coprococcus catus, Monoglobus, and Lachnospiraceae GCA-900066575, while being enriched in Oscillibacter valericigenes, Negativibacillus massiliensis, and three genera of the Ruminococcaceae family. Of these, only the Ruminococcaceae taxa were also enriched in healthy children not consuming cow's milk. Furthermore, the gut microbiome of children who developed tolerance and had received an HF was similar to that of healthy children, whereas that of children who had not received an HF was significantly different. Our results demonstrate that specific gut microbiome signatures are associated with CMA, which differ from those of dietary milk elimination. Moreover, HF consumption affects the gut microbiome of children who develop tolerance.

Goat Milk Allergy and a Potential Role for Goat Milk in Cow's Milk Allergy.

In many parts of the world, goat milk has been part of the human diet for millennia. Allergy to goat's milk, not associated with allergy to cow's milk, is a rare disorder, although some cases have been described. Goat milk proteins have substantial homology with cow's milk proteins and even show cross-reactivity; therefore, they are not advised as an alternative to cow's milk for infants with IgE-mediated cow's milk allergies. However, there are indications that, due to the composition of the goat milk proteins, goat milk proteins show lower allergenicity than cow's milk due to a lower αS1-casein content. For this reason, goat milk might be a better choice over cow's milk as a first source of protein when breastfeeding is not possible or after the breastfeeding period. Additionally, some studies show that goat milk could play a role in specific types of non-IgE-mediated cow milk allergy or even in the prevention of sensitization to cow's milk proteins. This review discusses a possible role of goat milk in non-IgE mediated allergy and the prevention or oral tolerance induction of milk allergy.

The evolution of Cow's Milk-related Symptom Score (CoMiSS™) in presumed healthy infants.

The Cow's Milk-related Symptom Score (CoMiSS™) is a scoring system that reflects the appearance and intensity of symptoms possibly related to consumption of cow's milk. The original tool was recently updated by changing the cut-off, and the stool scale and by adding angioedema. There is no data available regarding the natural evolution of CoMiSS in infants with no cow's milk allergy (no-CMA) or a comparison between original and updated CoMiSS values. We determined the original and the updated CoMiSS in infants not diagnosed with cow's milk allergy. The evolution of CoMiSS during the first year of life was assessed repetitively during predefined check-ups at 1.5, 3, 4, 6, 8, 10, and 12 months. The original and updated scores were compared with the Wilcoxon Signed-Rank Test. We also tested the impact of feeding type, age, gender, and order in the family on the CoMiSS. One hundred and twenty-two infants were included. CoMiSS values during the first year of life showed an inverse relation to age. The difference in CoMiSS between the original and updated versions was significant at 6,8,10, and 12 months (p < 0.001), related to the switch from the Bristol Stool Form Scale to the Brussels Infants and Toddlers Stool Scale (BITSS). The difference between both versions of CoMiSS was not significantly different in infants < 6 months (p = 0.999 at 1.5 and 4 months, and p = 0.586 at 3 months, respectively).Conclusion: CoMiSS decreases with age during the first year of life. While there is no difference between the two CoMiSS versions in healthy infants under 6 months of age, the CoMiSS value in the updated version is lower than the original 1 in infants aged 6 to 12 months. What is known? • The Cow's Milk-related Symptom Score (CoMiSS) is a validated awareness tool for cow's milk allergy (CMA). • A CoMiSS of ≥ 10 indicates a risk for cow's milk allergy. What is new? • The natural evolution of CoMiSS in infants not diagnosed with CMA (no-CMA) shows an inverse relation to age. • There is no difference between the original and the updated CoMiSS versions in no-CMA-infants under six months of age, but the updated CoMiSS is lower in infants 6-12 months than the original one.

The contribution of milk substitutes to the nutritional status of children with cow's milk allergy.

BACKGROUND: The impact of alternative milk substitutes on the nutritional status of children with cow's milk allergy (CMA), the prevailing cause of food allergies, is unresolved. METHODS: A cross-sectional study was performed in children older than 2 years with IgE-mediated CMA. Patients' clinical characteristics, anthropometric measurements, dietary intake (by 3-day food diary), and biochemical markers of nutritional status were assessed. RESULTS: One hundred two children with CMA (68.6% boys; median age, 3.7 years; 51% multiple food allergies) were evaluated. 44.1% of the children consumed plant-based beverages (PBB), 19.6% therapeutic formula and 36.3% did not consume any milk substitutes. In all age groups, dietary calcium, riboflavin, and vitamin D intake of those who did not use milk substitutes were lower than those who consumed formula or PBB (p < .01). Also in the 2-3 years old age group, dietary zinc (p = .011) and iron intake (p = .004) of the formula-fed group was higher. Formula-fed patients had higher levels of 25-OH vitamin D (µg/L) and serum vitamin B12 (ng/L) than PBB-fed patients (respectively; p < .001, p = .005) and those who did not consume any milk substitute (p < .001). Patients of all ages who did not utilize a milk substitute failed to obtain an adequate amount of dietary calcium. CONCLUSION: The use of milk substitutes positively affects dietary calcium, riboflavin, and vitamin D intake in CMA, but their contribution is variable. Those who do not use milk substitutes are at greater risk inadequate of dietary calcium intake. Personalized nutritional advice, given the clinical diversity and the impact of individual differences, is required.

Long-term efficacy and safety of cow's milk anaphylaxis specific immunotherapy: Allergen unresponsiveness via the Tolerance Induction Program.

Background: Tolerance Induction Program (TIP) immunotherapy applies machine learning contextualized on immunologic and food protein data sets. TIP has established efficacy toward peanut allergy. This form of treatment demonstrates equal efficacy toward cow's milk anaphylaxis. TIP maintains remission outcomes defined as a minimum of 7 days of allergen unresponsiveness to high-dose protein exposures. Furthermore, remission patients openly consume unrestricted amounts of dairy protein. Objective: We sought to assess the rate of decline in specific IgE specific whole and component-resolved diagnostics following 1 year of TIP milk immunotherapy. Methods: The study comprised 214 cow milk anaphylactic children who underwent TIP at the Translational Pulmonary & Immunology Research Center/Food Allergy Institute. Postintervention changes in cow milk specific IgE, component-resolved diagnostics, and specific IgG4 were assessed. Results: After 1 year of 10-g dairy protein weekly sustained unresponsiveness, eosinophil count decreased from 558.38 to 409.26 cells/µL, the mean cow milk IgE decreased from 16.91 to 9.10 kU/L, the mean boiled cow milk IgE decreased from 12.89 to 6.03 kU/L, the mean Bos D4 decreased from 7.38 to 3.52 kU/L, the mean Bos D5 decreased from 6.79 to 3.16 kU/L, and the mean Bos D8 decreased from 13.55 to 6.62 kU/L. Adverse events were rare. Conclusions: TIP cow milk immunotherapy significantly reduced cow milk specific IgE and component-resolved diagnostics while increasing specific IgG4 in cow milk anaphylactic children. TIP demonstrates safety and clinical efficacy in cow milk anaphylaxis treatment.

Allergen-specific B cell responses in oral immunotherapy-induced desensitization, remission, and natural outgrowth in cow's milk allergy.

BACKGROUND: Antigen-specific memory B cells play a key role in the induction of desensitization and remission to food allergens in oral immunotherapy and in the development of natural tolerance (NT). Here, we characterized milk allergen Bos d 9-specific B cells in oral allergen-specific immunotherapy (OIT) and in children spontaneously outgrowing cow's milk allergy (CMA) due to NT. METHODS: Samples from children with CMA who received oral OIT (before, during, and after), children who naturally outgrew CMA (NT), and healthy individuals were received from Stanford biobank. Bos d 9-specific B cells were isolated by flow cytometry and RNA-sequencing was performed. Protein profile of Bos d 9-specific B cells was analyzed by proximity extension assay. RESULTS: Increased frequencies of circulating milk allergen Bos d 9-specific B cells were observed after OIT and NT. Milk-desensitized subjects showed the partial acquisition of phenotypic features of remission, suggesting that desensitization is an earlier stage of remission. Within these most significantly expressed genes, IL10RA and TGFB3 were highly expressed in desensitized OIT patients. In both the remission and desensitized groups, B cell activation-, Breg cells-, BCR-signaling-, and differentiation-related genes were upregulated. In NT, pathways associated with innate immunity characteristics, development of marginal zone B cells, and a more established suppressor function of B cells prevail that may play a role in long-term tolerance. The analyses of immunoglobulin heavy chain genes in specific B cells demonstrated that IgG2 in desensitization, IgG1, IgA1, IgA2, IgG4, and IgD in remission, and IgD in NT were predominating. Secreted proteins from allergen-specific B cells revealed higher levels of regulatory cytokines, IL-10, and TGF-ß after OIT and NT. CONCLUSION: Allergen-specific B cells are essential elements in regulating food allergy towards remission in OIT-received and naturally resolved individuals.

A retrospective comparison of IgE-mediated cow's milk protein allergy management strategies in pediatric cohorts.

BACKGROUND: Complete avoidance of milk is the usual management for IgE-mediated cow's milk protein allergy (CMPA). A baked milk ladder is a method of dietary advancement therapy in IgE-mediated CMPA in Ireland, while in Spain, avoidance of milk awaiting natural tolerance acquisition through an oral food challenge (OFC) is employed. The aim of this study was to evaluate the use of dietary advancement therapy using a milk ladder compared with complete avoidance of milk for managing IgE-mediated CMPA. METHODS: This is a retrospective chart review of 371 pediatric patients from the population who have been treated for IgE-mediated CMPA between 2011 and 2020, with the milk ladder (Ireland) or complete avoidance followed by an OFC (Spain). The main outcome was the introduction of cow's milk. RESULTS: Milk ladder patients were 3.67 times more likely to succeed in comparison with milk avoidance (p < .001). Anaphylaxis during the treatment period occurred in 34 patients in the milk avoidance groups, while three patients in the milk ladder group experienced anaphylaxis due to accidental exposure to milk (p < .001). Failure to complete treatment was associated with a higher skin prick test in the milk avoidance group and a raised specific IgE in the milk ladder group. CONCLUSION: This is the first study that compares outcomes of dietary advancement therapy to complete avoidance for CMPA management, demonstrating that cow's milk can be successfully and safely reintroduced using dietary advancement therapy using a milk ladder.