The Impact of Formula Choice for the Management of Pediatric Cow's Milk Allergy on the Occurrence of Other Allergic Manifestations: The Atopic March Cohort Study.

OBJECTIVES: To compare the impact of different formulas on the occurrence of other atopic manifestations and the time of immune tolerance acquisition. STUDY DESIGN: In a 36-month prospective cohort study, the occurrence of other atopic manifestations (eczema, urticaria, asthma, and rhinoconjunctivitis) and the time of immune tolerance acquisition were comparatively evaluated in immunoglobulin E-mediated children with cow's milk allergy (CMA) treated with extensively hydrolyzed casein formula containing the probiotic L. rhamnosus GG (EHCF + LGG), rice hydrolyzed formula, soy formula, extensively hydrolyzed whey formula (EHWF), or amino acid-based formula. RESULTS: In total, 365 subjects were enrolled into the study, 73 per formula cohort. The incidence of atopic manifestations was 0.22 (Bonferroni-corrected 95% CI 0.09-0.34) in the EHCF + LGG cohort; 0.52 (0.37-0.67) in the rice hydrolyzed formula cohort; 0.58 (0.43-0.72) in the soy formula cohort; 0.51 (0.36-0.66) in the EHWF cohort; and 0.77 (0.64-0.89) in the amino acid-based formula cohort. The incidence of atopic manifestations in the rice hydrolyzed formula, soy formula, EHWF, and amino acid-based formula cohorts vs the EHCF + LGG cohort was always greater than the prespecified absolute difference of 0.25 at an alpha-level of 0.0125, with corresponding risk ratios of 2.37 (1.46-3.86, P < .001) for rice hydrolyzed formula vs EHCF + LGG; 2.62 (1.63-4.22, P < .001) for soy formula vs EHCF + LGG; 2.31 (1.42-3.77, P < .001) for EHWF vs EHCF + LGG; and 3.50 (2.23-5.49, P < .001) for amino acid-based formula vs EHCF + LGG. The 36-month immune tolerance acquisition rate was greater in the EHCF + LGG cohort. CONCLUSIONS: The use of EHCF + LGG for CMA treatment is associated with lower incidence of atopic manifestations and greater rate of immune tolerance acquisition.

Dietary Treatment with Extensively Hydrolyzed Casein Formula Containing the Probiotic Lactobacillus rhamnosus GG Prevents the Occurrence of Functional Gastrointestinal Disorders in Children with Cow's Milk Allergy.

OBJECTIVE: To investigate whether the addition of the probiotic Lactobacillus rhamnosus GG (LGG) to the extensively hydrolyzed casein formula (EHCF) for cow's milk allergy (CMA) treatment could reduce the occurrence of functional gastrointestinal disorders (FGIDs). STUDY DESIGN: This cohort study included children with a positive history for CMA in the first year of life who were treated with EHCF alone or in combination with LGG and had evidence of immune tolerance acquisition to cow's milk for at least 12 months. FGID was diagnosed according to the Rome III diagnostic criteria by investigators unaware of previous treatment. A cohort of consecutive healthy children was also evaluated as a control population. RESULTS: A total of 330 subjects were included, 110 per cohort (EHCF, EHCF+LGG, and healthy controls). The rate of subjects with ≥1 FGID was significantly lower in the EHCF+LGG cohort compared with the EHCF cohort (40% vs 16.4%; P < .05). In the EHCF+LGG cohort, a lower incidence was observed for all components of the main study outcome. The prevalence of FGIDs in the healthy cohort was lower than that in the EHCF cohort and similar to that in the EHCF+LGG cohort. The incidence rate ratio of FGIDs for the EHCF+LGG cohort vs the EHCF cohort (0.40; 95% CI, 0.25-0.65; P < .001) was unmodified after correction for age at CMA diagnosis, breastfeeding, weaning time, and presence of a first-degree relative with an FGID. CONCLUSIONS: These results confirm the increased risk for developing FGIDs in children with CMA and suggest that EHCF+LGG could reduce this risk.

The efficiency of the symptom-based score in infants diagnosed with cow's milk protein and hen's egg allergy.

INTRODUCTION AND OBJECTIVES: Symptom-based score (SBS) quantifies the number and severity of suspected cow's milk-related symptoms. In this study, we aimed to evaluate the efficiency of SBS in patients diagnosed with cow's milk protein (CMPA) and hen's egg allergy (HEA). MATERIALS AND METHODS: A single-center study was conducted between June 2015 and August 2017. Infants who were diagnosed with CMPA and HEA or both were enrolled in the study. SBS was applied at baseline and at one month during an elimination diet. RESULTS: One hundred and twelve patients were enrolled in the study. Of these, 56 (50%) were female. Forty-nine (43.8%) patients were diagnosed with CMPA, 39 (34.8%) patients were diagnosed with HEA and 24 (21.4%) patients were diagnosed with cow's milk protein and hen's egg allergy (CMPHEA). In the analysis of SBS, median Bristol scale and initial total symptom-based scores were significantly lower in the HEA group than others (p=0.002; p=0.025). After the elimination diet, mean SBS decrease in the CMPHEA group (11.3±4.7) was found to be higher than CMPA (8.8±3.7) and HEA (8.0±4.0) groups (p=0.009). In 41 (83.7%) patients with CMPA, 33 (84.6%) patients with HEA and 21 (87.5%) patients with CMPHEA, a ≥50% decrease in SBS was observed after the elimination diet. CONCLUSION: We may conclude that the present study suggests that SBS can be useful in monitoring the response to elimination diet in infants diagnosed with cow's milk protein and hen's egg allergy.

[Update on management of cow's milk protein allergy: Available milk formulas and other juices]. / Actualización en manejo de Alergia a la proteína de leche de vaca: fórmulas lácteas disponibles y otros brebajes.

Cow's milk protein allergy (CMPA) is a common disease with a prevalence of 2-7%, increasingly so. It is characterized by an allergic reaction to one or more cow's milk proteins. There are not pathog nomonic clinical symptoms, and these will depend on the type of immune reaction involved. A good diagnostic approach avoids under and over diagnosis and, therefore, under and over treatment. The CMPA treatment is the elimination of cow's milk protein from the diet. A restricted diet in a child does not require it or who has developed tolerance can alter growth, quality of life, including unne cessary costs. The objective of this review is to present the different milk formulas available in Chile to treat CMPA in those cases where breastfeeding with exclusion diet is not possible. For this purpose, nutritional composition, ingredients and other relevant characteristics of all the milk formulas and juices marketed in Chile as CMPA treatment were reviewed. The information was obtained from the official distributors or sellers or failing that, from the official websites. There are multiple milk formulas and beverages used for the treatment of CMPA, and not all of them are nutritionally or immunologically secure. Knowing them in detail will help the pediatrician to indicate them in a more informed way according to their benefits and their deficiencies for the proper management of this pathology.

Actualización en manejo de alergia a la proteína de leche de vaca: fórmulas lácteas disponibles y otros brebajes / Update on management of cow's milk protein allergy: available milk formulas and other juices

La alergia a la proteína de leche de vaca (APLV) es una enfermedad frecuente, con una prevalencia entre 2-7%, cifras que van en aumento. Se caracteriza por una reacción alérgica a una o más pro teínas de la leche de vaca. No existen manifestaciones clínicas patognomónicas, y éstas dependerán del tipo de reacción inmunológica involucrada. Una buena aproximación diagnóstica evita el sub y sobre diagnóstico y por lo tanto, sub y sobre tratamiento. El tratamiento de la APLV es la eliminación de la proteína de leche de vaca de la dieta. Una dieta de restricción en un niño que no la requiere o que ha desarrollado tolerancia, puede alterar el crecimiento, la calidad de vida y producir costos innecesarios. El objetivo de esta actualización es presentar las diferentes fórmulas y brebajes usados en Chile para tratar la APLV en aquellos casos en que no sea posible la lactancia materna con dieta de exclusión. Para ello se revisó la composición nutricional, ingredientes y otras características relevan tes de todas aquellas fórmulas o brebajes que se comercializan en Chile como tratamiento de APLV. La información se obtuvo desde los distribuidores o vendedores oficiales, o en su defecto, desde las páginas web oficiales. Se puede concluir que existen y se usan múltiples fórmulas y brebajes para el tratamiento de APLV, no todas ellas del todo adecuadas desde el punto de vista nutricional y de seguridad. Conocerlas en detalle ayudará al pediatra a indicarlas de manera más informada de acuerdo a sus beneficios y sus carencias para el manejo adecuado de esta patología.

Cow's milk protein allergy (CMPA) is a common disease with a prevalence of 2-7%, increasingly so. It is characterized by an allergic reaction to one or more cow's milk proteins. There are not pathog nomonic clinical symptoms, and these will depend on the type of immune reaction involved. A good diagnostic approach avoids under and over diagnosis and, therefore, under and over treatment. The CMPA treatment is the elimination of cow's milk protein from the diet. A restricted diet in a child does not require it or who has developed tolerance can alter growth, quality of life, including unne cessary costs. The objective of this review is to present the different milk formulas available in Chile to treat CMPA in those cases where breastfeeding with exclusion diet is not possible. For this purpose, nutritional composition, ingredients and other relevant characteristics of all the milk formulas and juices marketed in Chile as CMPA treatment were reviewed. The information was obtained from the official distributors or sellers or failing that, from the official websites. There are multiple milk formulas and beverages used for the treatment of CMPA, and not all of them are nutritionally or immunologically secure. Knowing them in detail will help the pediatrician to indicate them in a more informed way according to their benefits and their deficiencies for the proper management of this pathology.

Evidence for Involvement of IL-9 and IL-22 in Cows' Milk Allergy in Infants.

Although allergic inflammation is characterized by a T helper (Th) 2-dominant immune response, the discovery of a role for new T cell subsets in inflammatory diseases has added an additional layer of complexity to the understanding of the pathogeneses of allergic diseases. We evaluated plasma cytokine profiles in infants with cows' milk allergy (CMA), who were being treated with an elimination diet. In a prospective, randomized and controlled study, infants (aged 8.4 ± 3.9 months) with CMA were treated with an elimination diet for 120 days, which replaced cows' milk with a hydrolysed soy protein formula (n = 26) or a free amino acid formula (n = 20). Blood samples were collected before treatment during active disease (T0) and after 120 days, when symptoms were absent (T1). Plasma cytokine concentrations were measured. Infants with CMA had higher plasma concentrations of interleukin (IL)-4 and IL-13 and lower concentrations of IL-9, IL-17A and interferon-γ, compared with healthy breast-fed infants. At T0, there was a positive correlation between blood eosinophil numbers and plasma concentrations of IL-4, IL-9, IL-17A and IL-22. Treatment with a cows' milk elimination diet resulted in a decrease in plasma IL-4, IL-9, IL-13 and IL-22 and an increase in plasma IL-17A. We conclude that IL-4 and IL-13 are elevated in active CMA. The association of IL-9 and IL-22 with eosinophilia, and the decrease in these two cytokines with cows' milk elimination, suggests that they both play a role in the symptoms observed in CMA and may be important targets for future interventions.

Nutricionistas das Unidades Básicas de Saúde, dos Núcleos Regionais de Atendimento Domiciliar e da Área Clínica de uma instituição pública: conhecimentos de nutrição observados entre estes profissionais sobre o tratamento de alergia ao leite de vaca no lactente / Nutritionists of Basic Health Units, Regional Centers of Home Care and Clinic Area Public Health: knowledge of nutrition observed between the professionals about the treatment of cow's milk allergy in infants

Objetivo: Analisar o conhecimento científico dos nutricionistas das Unidades Básicas de Saúde, dos Núcleos Regionais de Atendimento Domiciliar e de Área Clínica da rede pública de saúde do Distrito Federal sobre o tratamento nutricional da alergia ao leite de vaca em lactentes. Método: Estudo transversal analítico realizado com 48 nutricionistas. Resultados: Todas as nutricionistas são do sexo feminino e 72,91% têm especialização em nutrição infantil e em outras áreas e 70,80% trabalham 40 horas/semana. Não há associação estatisticamente significativa entre o grau de especialização das nutricionistas e a frequência de atendimento aos lactentes (p=0,6603) e nem entre a jornada de trabalho com a frequência de atendimento (p=0,4647). As nutricionistas que atuam em Clínica apresentaram maior nível de acertos nas práticas de tratamento e conhecimento, seguidas das de Unidades Básicas de Saúde. Conclusão: As nutricionistas das três áreas demonstraram amplo conhecimento sobre os protocolos e práticas relacionadas ao tratamento da alergia. Participação em capacitações, acesso a informações e pesquisas científicas podem contribuir para um tratamento mais efetivo e de qualidade.(AU)

Objective: To analyze the scientific knowledge of the nutritionists of the Basic Health Units, the Regional Centers for Home Care and the Clinical Area of the public health system of the Federal District about the nutritional treatment of cow's milk allergy in infants. Methods: An analytical cross-sectional study with 48 nutritionists. Results: All nutritionists are female and 72.91% specialize in child nutrition and other areas and 70.80% work 40 hours a week. There was no statistically significant association between the degree of specialization of nutritionists and the frequency of care for infants (p=0.6603) or between the working day and attendance frequency (p=0.4647). Nutritionists who work in Clinic presented a higher level of correctness in treatment and knowledge practices, followed by Basic Health Units. Conclusion: Nutritionists in the three areas showed a broad knowledge of the protocols and practices related to the treatment of allergy. Participation in training, access to information and scientific research can contribute to a more effective and quality treatment.(AU)

Alergia ao leite de vaca: achados do ultrassom com Doppler colorido em neonatos com hematoquezia / Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

OBJETIVO: o ultrassom (US) tem sido uma importante ferramenta de diagnóstico para identificar várias causas de hemorragia gastrointestinal. Neonatos com alergia ao leite de vaca (ALV) podem apresentar hematoquezia, e a confirmação do diagnóstico pode ser difícil. O objetivo deste estudo é descrever achados com ultrassom em escala de cinza e com Doppler colorido em pacientes com ALV. MÉTODOS: estudamos, retrospectivamente, 13 neonatos com ALV. Todos eles apresentaram hematoquezia severa e dor abdominal e foram submetidos a um estudo com US, com o diagnóstico de colite alérgica. O diagnóstico teve como base os achados clínicos, a recuperação após a dieta de exclusão do neonato ou da mãe, no caso de amamentação exclusiva, e o teste de provocação oral positivo. RESULTADOS: a idade média variou de um a seis meses (média = 3,53). Sete dos 13 neonatos (53,8%) passaram novamente por ultrassonografia em escala de cinza e com Doppler colorido após a dieta de exclusão. Dentre eles, 12 dos 13 (92,3%) mostraram anormalidades no US e no ultrassom com Doppler colorido (USDC) no início. Os achados positivos que sugeriram colite foram paredes intestinais espessas e aumento na vascularização, principalmente no cólon descendente e sigmoide. Os resultados da colonoscopia e histopatológicos foram compatíveis com colite alérgica. Após uma mudança na dieta, os 13 neonatos se recuperaram e seus testes de provocação oral foram positivos. CONCLUSÃO: o US com Doppler pode ser muito útil para diagnosticar a colite secundária, como a ALV, e para excluir várias outras doenças abdominais que podem imitar essa doença.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean = 3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean=3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Clinical and follow up assessment of children in a program directed at the use of formulas for cow's milk protein allergy.

OBJECTIVE: To determine clinical and follow up characteristics of children enrolled in a program to supply formulas for cow's milk allergy. METHODS: descriptive study of a convenience sample composed of 214 children up to three years old, with clinical diagnosis of cow's milk allergy and/or standardized oral challenge, referred to the Program of Formulas for Cow's Milk Allergy at a Pediatric University Hospital, in Natal, Rio Grande do Norte, Brazil (2007/2009). Clinical-epidemiological data and formula indication (soy, protein hydrolysates or aminoacid formula) were assessed at the first consultation. Clinical response and nutritional evolution (Anthro-OMS2006) were observed after three months. Chi-square and paired t-test were used, being p<0.05 significant. RESULTS: At the first consultation, mean age was 9.0±6.9 months. Digestive manifestations occurred in 81.8%; cutaneous ones, in 36.9% and respiratory ones in 23.8%. BMI Z-score <-2.0 standard deviations (SD) was found in 17.9% of children with isolated digestive symptoms, in 41.7% of those using cow's milk and in 8.7% of those using other formulas (p<0.01). The following formulas were used: soy in 61.2%, protein hydrolysates in 35.4% and aminoacids in 3.3%. Mean BMI Z-scores at initial consultation and after three months were, respectively: -0.24±1.47SD and 0.00±1.26SD (p=0.251), with soy formula, and -0.70±1.51SD and -0.14±1.36SD (p=0.322) with protein hydrolysates formula. CONCLUSIONS: Digestive manifestations of cow's milk allergy were preponderant, and lead to greater nutritional impairment. The use of replacement formulas (isolated soy protein and protein hydrolysates) was important to maintain the nutritional status.

Avaliação clínica e evolutiva de crianças em programa de atendimento ao uso de fórmulas para alergia à proteína do leite de vaca / Clinical and follow up assessment of children in a program directed at the use of formulas for cow's milk protein allergy / Evaluación clínica y evolutiva de niños en programas de atención al uso de fórmulas para alergia a la proteína de leche de vaca

OBJETIVO: Determinar características clínicas e evolutivas de crianças acompanhadas em programa de referência para fornecimento de fórmulas especiais para alergia ao leite de vaca. MÉTODOS: Estudo descritivo, realizado em amostra de conveniência, com 214 crianças até três anos, com diagnóstico clínico e/ou teste padronizado de provocação oral aberto, referenciadas ao Programa de Fórmulas para Alergia ao Leite de Vaca, em Hospital Universitário Pediátrico de Natal, Rio Grande do Norte (2007/2009). Avaliaram-se dados clínico-epidemiológicos e indicação de fórmulas (soja, hidrolisado ou aminoácido) à consulta inicial, além de resposta clínica e evolução nutricional (Anthro-OMS 2006) após três meses. Aplicaram-se os testes do qui-quadrado e t pareado nas análises, considerando-se significante p<0,05. RESULTADOS: Ao primeiro atendimento, a média de idade foi de 9,0±6,9 meses. Manifestações digestórias foram observadas em 81,8%; cutâneas, em 36,9%; e respiratórias, em 23,8%. Escore Z do IMC <-2,0 desvios padrão (DP) foi encontrado em 17,9% das crianças com sintomas digestórios isolados, em 41,7% em uso de leite de vaca e em 8,7% com outras fórmulas (p<0,01). Fórmula de proteína isolada de soja foi usada em 61,2%; hidrolisados, em 35,4%; e aminoácidos, em 3,3%. As médias de escore Z do IMC ao atendimento inicial e após três meses foram, respectivamente, -0,24±1,47DP e 0,00±1,26DP (p=0,251), quando em uso de soja, e -0,70±1,51DP e -0,14±1,36DP (p=0,322), em uso de hidrolisado. CONCLUSÕES: Manifestações digestórias da alergia ao leite de vaca foram preponderantes e determinaram maior comprometimento nutricional. As fórmulas de substituição ao leite de vaca mais utilizadas foram de proteína isolada de soja e hidrolisados proteicos. O uso de ambas foi importante para a manutenção do estado nutricional.

OBJECTIVE: To determine clinical and follow up characteristics of children enrolled in a program to supply formulas for cow's milk allergy. METHODS: descriptive study of a convenience sample composed of 214 children up to three years old, with clinical diagnosis of cow's milk allergy and/or standardized oral challenge, referred to the Program of Formulas for Cow's Milk Allergy at a Pediatric University Hospital, in Natal, Rio Grande do Norte, Brazil (2007/2009). Clinical-epidemiological data and formula indication (soy, protein hydrolysates or aminoacid formula) were assessed at the first consultation. Clinical response and nutritional evolution (Anthro-OMS2006) were observed after three months. Chi-square and paired t-test were used, being p<0.05 significant. RESULTS: At the first consultation, mean age was 9.0±6.9 months. Digestive manifestations occurred in 81.8%; cutaneous ones, in 36.9% and respiratory ones in 23.8%. BMI Z-score <-2.0 standard deviations (SD) was found in 17.9% of children with isolated digestive symptoms, in 41.7% of those using cow's milk and in 8.7% of those using other formulas (p<0.01). The following formulas were used: soy in 61.2%, protein hydrolysates in 35.4% and aminoacids in 3.3%. Mean BMI Z-scores at initial consultation and after three months were, respectively: -0.24±1.47SD and 0.00±1.26SD (p=0.251), with soy formula, and -0.70±1.51SD and -0.14±1.36SD (p=0.322) with protein hydrolysates formula. CONCLUSIONS: Digestive manifestations of cow's milk allergy were preponderant, and lead to greater nutritional impairment. The use of replacement formulas (isolated soy protein and protein hydrolysates) was important to maintain the nutritional status.

OBJETIVO: Determinar características clínicas y evolutivas de niños acompañados en programa de referencia para suministro de fórmulas especiales para alergia a la leche de vaca. MÉTODOS: Estudio descriptivo, realizado en muestra de conveniencia, con 214 niños hasta tres años de edad, con diagnóstico clínico y/o prueba estandarizada de provocación oral abierta, referenciadas al Programa de Fórmulas para Alergia a la Leche de Vaca del Hospital Universitario Pediátrico en Natal, RN, Brasil (2007/2009). Se evaluaron datos clínico-epidemiológicos e indicación de fórmulas (soja, hidrolizado o aminoácido) a la consulta inicial, respuesta clínica y evolución nutricional (Anthro-OMS 2006) después de tres meses. Se aplicaron pruebas de Chi-Cuadrado y T Pareada en los análisis, siendo significante p<0,05. RESULTADOS: A la primera atención, el promedio de edad fue de 9,0±6,9 meses. Manifestaciones digestorias fueron observadas en 81,8%, cutáneas en el 36,9% y respiratorias en el 23,8%. Escore Z IMC<-2,0DE fue encontrado en 17,9% de los niños con síntomas digestorios aislados, en el 41,7% en uso de leche de vaca y en 8,7% en otras fórmulas (p<0,01). Se utilizó fórmula de proteína aislada de soja en 61,2%, hidrolizados en 35,4% y aminoácidos en 3,3%. Promedios de Escore Z IMC a la atención inicial y después de tres meses fueron -0,24±1,47DE y 0,00±1,26DE (p=0,251), cuando en uso de soja, y 0,70±1,51DE y -0,14±1,36DE (p=0,322), en uso de hidrolizado. CONCLUSIONES: Manifestaciones digestorias de la alergia a la leche de vaca fueron preponderantes y determinaron mayor comprometimiento nutricional. Las fórmulas de sustitución a la leche de vaca más utilizadas fueron de proteína aislada de soja e hidrolizados proteicos y el uso de ambas fue importante para el mantenimiento del estado nutricional.

Formula selection for management of children with cow's milk allergy influences the rate of acquisition of tolerance: a prospective multicenter study.

OBJECTIVES: To prospectively evaluate the effect of different dietary management strategies on the rate of acquisition of tolerance in children with cow's milk allergy (CMA). STUDY DESIGN: Otherwise healthy children (aged 1-12 months) diagnosed with CMA were prospectively evaluated. The study population was divided into 5 groups based upon the formula used for management: (1) extensively hydrolyzed casein formula ([EHCF], n = 55); (2) EHCF + Lactobacillus rhamnosus GG [LGG], n = 71); (3) hydrolyzed rice formula (RHF, n = 46); (4) soy formula (n = 55); and (5) amino acid based formula (n = 33). A food challenge was performed after 12 months to assess acquisition of tolerance. RESULTS: Two hundred sixty children were evaluated (167 male, 64.2%; age 5.92 months, 95% CI 5.48-6.37; body weight 6.66 kg, 95% CI 6.41-6.91; IgE-mediated CMA 111, 42.7%). The rate of children acquiring oral tolerance after 12 months was significantly higher (P < .05) in the groups receiving EHCF (43.6%) or EHCF + LGG (78.9%) compared with the other groups: RHF (32.6%), soy formula (23.6%), and amino acid based formula (18.2%). Binary regression analysis coefficient (B) revealed that the rate of patients acquiring tolerance at the end of the study was influenced by 2 factors: (1) IgE-mediated mechanism (B -2.05, OR 0.12, 95% CI 0.06-0.26; P < .001); and (2) formula choice, such that those receiving either EHCF (B 1.48, OR 4.41, 95% CI 1.44-13.48; P = .009) or EHCF + LGG (B 3.35, OR 28.62, 95% CI 8.72-93.93; P < .001). CONCLUSIONS: EHCF accelerates tolerance acquisition in children with CMA if compared with other dietetic choices. This effect is augmented by LGG.

[Cow's milk protein allergy in disability children]. / Alergia a las proteínas de leche de vaca en niños con discapacidad.

BACKGROUND: Cow's milk protein allergy (CMPA) is the most common food allergy in children. However, the prevalence of CMPA in disability children is unknown. OBJECTIVE: To know the frequency of CMPA in disability children and to assess the clinical improvement after a suppression diet. MATERIAL AND METHODS: We conducted a cohort study at the Children's Rehabilitation Center Telethon of Puebla, in which children aged 6 months to 5 years with clinical symptoms of CMPA were included, between January and September 2012. An exploratory questionnaire about clinical symptoms of CMPA was applied before and after the cow's milk proteins suppression diet. RESULTS: We identified 26 cases among 145 assessed children (18%). The mean age was 2 years and 7 months. All children had a history of multiple clinical symptoms. Respiratory symptoms were the most common, follows for gastrointestinal symptoms, including regurgitation, which suggests the association with gastroesophageal reflux. CONCLUSIONS: CMPA is frequent in disability children. Respiratory and gastrointestinal symptoms were the most common. Cow's milk proteins suppression diet was a useful diagnostic and therapy tool for these children.

ANTECEDENTES: la alergia a las proteínas de la leche de vaca es la alergia alimentaria más frecuente en niños. Sin embargo, se desconoce la prevalencia de ésta en niños con discapacidad. OBJETIVO: conocer la frecuencia de alergia a las proteínas de la leche de vaca en niños con discapacidad y evaluar la mejoría clínica posterior a una dieta de supresión. MATERIAL Y MÉTODO: estudio de cohorte efectuado en pacientes con datos clínicos de alergia a las proteínas de la leche de vaca, de seis meses a cinco años de edad, atendidos en el Centro de Rehabilitación Infantil Teletón de Puebla, de enero a septiembre de 2012. Se aplicó un cuestionario de manifestaciones clínicas de alergia a las proteínas de la leche de vaca antes y después de una dieta de supresión de proteínas de leche de vaca. RESULTADOS: se identificaron 26 casos entre 145 niños evaluados (18%). La media de edad fue de 2 años y 7 meses. Todos los niños tenían antecedentes de múltiples manifestaciones clínicas; las más frecuentes fueron las respiratorias, seguidas por las digestivas, que incluyeron regurgitaciones, lo que sugiere asociación con reflujo gastroesofágico. Todos los pacientes mostraron mejoría clínica después de la dieta de supresión. CONCLUSIONES: la alergia a las proteínas de la leche de vaca es frecuente en niños con discapacidad. Las manifestaciones respiratorias y digestivas fueron las más comunes. La dieta de supresión de proteínas de leche de vaca resultó en un procedimiento diagnóstico y de tratamiento de gran valor en este grupo de niños.

Open challenge for the diagnosis of cow's milk protein allergy.

OBJECTIVE: To report the results of open challenge tests performed in children fed with cow's milk-free diet. DESCRIPTION: Cross-sectional study evaluating cow's milk open challenge performed under supervision in a hospital setting during 2.5 hours and ambulatory follow-up for 30 days when no immediate reaction occurred. One hundred and twenty-one patients were included, with ages between 4 and 95 months. Cow's milk open challenge tests were positive in 28 patients (23.1%). A clinical manifestation of cow's milk allergy different from the one presented at diagnosis occurred in 12 (24.9%) patients with positive challenge. Positive challenge was more frequent (p = 0.042) in patients fed with extensively hydrolyzed formulae or amino acid-based formulae (30.3%) when compared to those fed with other exclusion diets (14.5%). CONCLUSION: Open challenge allowed the interruption of exclusion diet in a significant proportion of the patients.

Teste de desencadeamento aberto no diagnóstico de alergia à proteína do leite de vaca / Open challenge for the diagnosis of cow's milk protein allergy

OBJETIVO: Relatar os resultados de testes de desencadeamento aplicados em crianças alimentadas com dieta de exclusão das proteínas do leite de vaca. DESCRIÇÃO: Estudo transversal que avaliou testes de desencadeamento oral aberto, com leite de vaca, realizados sob supervisão em ambiente hospitalar por 2,5 horas e ambulatoriamente por 30 dias quando não ocorreu reação imediata. Foram incluídos 121 pacientes, com idades entre 4 e 95 meses. O teste de desencadeamento com leite de vaca foi positivo em 28 (23,1 por cento) pacientes. Manifestação clínica de alergia ao leite de vaca diferente da apresentada por ocasião da suspeita diagnóstica ocorreu em 12 (42,9 por cento) pacientes com desencadeamento positivo. O desencadeamento positivo foi mais frequente (p = 0,042) nos pacientes alimentados com fórmulas extensamente hidrolisadas ou de aminoácidos (30,3 por cento) quando comparados com os alimentados com outras dietas de exclusão (14,5 por cento). CONCLUSÃO: O teste de desencadeamento permitiu que fosse suspensa a dieta de exclusão de grande parte dos pacientes.

OBJECTIVES: To report the results of open challenge tests performed in children fed with cow's milk-free diet. DESCRIPTIONS: Cross-sectional study evaluating cow's milk open challenge performed under supervision in a hospital setting during 2.5 hours and ambulatory follow-up for 30 days when no immediate reaction occurred. One hundred and twenty-one patients were included, with ages between 4 and 95 months. Cow's milk open challenge tests were positive in 28 patients (23.1 percent). A clinical manifestation of cow's milk allergy different from the one presented at diagnosis occurred in 12 (24.9 percent) patients with positive challenge. Positive challenge was more frequent (p = 0.042) in patients fed with extensively hydrolyzed formulae or amino acid-based formulae (30.3 percent) when compared to those fed with other exclusion diets (14.5 percent). CONCLUSION: Open challenge allowed the interruption of exclusion diet in a significant proportion of the patients.

Hypoallergenicity and effects on growth and tolerance of a new amino acid-based formula with docosahexaenoic acid and arachidonic acid.

OBJECTIVE: In study 1, to compare the effect on growth in healthy infants of a new amino acid-based formula (AAF) and a control extensively hydrolyzed formula (EHF), with both docosahexaenoic acid (DHA) and arachidonic acid (ARA) at levels similar to those in human milk worldwide. In study 2, to evaluate the hypoallergenicity of this new AAF in infants and children with confirmed cow's milk allergy (CMA). STUDY DESIGN: In study 1, a total of 165 healthy, full-term, formula-fed infants randomly received the new AAF or control formula. Anthropometric measurements, tolerance, and adverse events were recorded throughout the study. Plasma amino acid profiles were evaluated in a subset of the infants. In study 2, the hypoallergenicity of the new AAF was evaluated in 32 infants and children using a double-blind, placebo-controlled food challenge; an open challenge; and a 7-day feeding. RESULTS: In study 1, overall growth, tolerance, and safety outcomes were similar in both groups. In study 2, 29 of the 32 subjects completed both challenges; no allergic reaction was seen in any of the 32 subjects. CONCLUSIONS: The new AAF with DHA and ARA at levels similar to those in human milk worldwide is hypoallergenic. It also is safe and supports growth in healthy, term infants.

Alergia a proteína do leite de vaca em crianças: repercussão da dieta de exclusão e dieta substitutiva sobre o estado nutricional / Cow's milk protein allergy in children: repercussion of the exclusion diet and replacement diet on the nutritional status

Identificar as repercussões nutricionais mais frequentes em crinças com alergia à proteína do leite de vaca. Fontes pesquisadas: artigos, livros, teses, 'sites' governamentais e científicos. Síntese dos dados: Crianças com alergia à proteína do leite de vaca, em dieta de exclusão...

To acknowledge he most frequent conseguences to nutritional status of children with cow milk protein allergy (CMPA). Sorces of research: reported papers, books, theses, and both governamental and scientific web pages...

The performance of parents of children receiving cow's milk free diets at identification of commercial food products with and without cow's milk.

OBJECTIVE: To investigate how well the parents of children on cow's milk free diets perform at recognizing whether or not expressions describe and foods contain cow's milk proteins. METHODS: Interviews were conducted with 24 parents of children on cow's milk and by-products exclusion diets and 23 parents of children with no need for any type of exclusion diet. They were asked if they recognized 12 expressions relating to cow's milk. They were then asked to classify 10 commercial food products in terms of whether or not they contained cow's milk proteins. RESULTS: Terms that included the word milk were more often recognized by both groups of parents. The parents of children on exclusion diets recognized the terms cow's milk protein, traces of milk and milk formulation or preparation most frequently (p < 0.05). Less than 25.0% of those interviewed recognized casein, caseinate, lactalbumin and lactoglobulin. Both groups correctly identified more of the commercial products containing cow's milk than those free from milk. The median number of products containing cow's milk (total = 5) correctly identified by the parents of children on exclusion diets (4.0) was greater than for the control group (3.0; p = 0.005). Reading at least one label was associated with a greater chance of correctly identifying more than five of the 10 products (odds ratio = 8.0). CONCLUSIONS: Despite having received guidance, the parents of children on exclusion diets were not fully prepared to manage these diets, indicating a need for improvements to the instruction provided when indicating exclusion diets.