Outcomes and factors associated with tolerance in infants with non-IgE-mediated cow's milk allergy with gastrointestinal manifestations

Abstract Objectives To evaluate outcomes of oral food challenge (OFC) test to assess tolerance in infants with non-IgE-mediated cow's milk allergy (CMA) with gastrointestinal manifestations and explore clinical data predictive of these outcomes. Methods Single-center retrospective study including infants (age < 12 months) who were referred for CMA between 2000 and 2018 and underwent OFC on follow-up. A univariate logistic regression test was performed to evaluate variables associated with the outcomes of the follow-up OFC test. Results Eighty-two patients were included, 50% were male. Eighteen patients had a positive OFC test (22%). Most patients had presented with hematochezia (77%). The median age of symptom onset was 30 days. Two-thirds of the patients were on appropriate infant formula (extensively hydrolyzed or amino acid-based formula), exclusively or in association with breastfeeding. The median time on an elimination diet before the OFC test was 8 months (Q1 6 - Q3 11 months). All cases with positive follow-up OFC tests (n= 18) had been exposed to cow's milk-based formula before the first clinical manifestation of CMA. Five out of eight cases with Food Protein-Induced Enterocolitis Syndrome (FPIES) had positive OFC tests. Exposure to cow's milk-based formula before diagnosis, a history of other food allergies, hematochezia and diarrhea were predictors of a positive OFC test. Conclusions In infants with non-IgE-mediated CMPA with gastrointestinal manifestations, the use of cow's milk-based formula, a history of other food allergies, and hematochezia and diarrhea upon initial presentation were associated factors for the later achievement of tolerance.

Alergia a la leche de vaca: ¿se pueden evitar las pruebas de provocación oral? Un análisis probabilístico basado en datos clínicos / Cow's milk allergy: Can oral food challenges be avoided? A probabilistic analysis based on clinical data

Introducción. La prueba de provocación oral (PPO) para el diagnóstico de alergia a las proteínas de la leche de la vaca (APLV) presenta riesgos y requiere de recursos. Nuestro objetivo fue evaluar condiciones y pruebas complementarias para identificar una alta probabilidad de APLV. Población y métodos. Análisis secundario sobre estudio de pacientes atendidos en una unidad de alergia entre 2015 y 2018. Se determinaron las probabilidades prepruebas asociadas a los síntomas y sus combinaciones, y las probabilidades pospruebas luego de realizadas pruebas cutáneas y determinación de inmunoglobulina E (IgE) sérica. Resultados. Se evaluó la información de 239 pacientes. Se observaron probabilidades mayores al 95 % en pacientes con angioedema y combinación de urticaria y vómitos. Usando puntos de corte propuestos por Calvani et al., la combinación de vómitos con rinitis, sin angioedema, también superó el 95 %. Conclusión. Se ofrece una metodología para identificar pacientes en los que puede diagnosticarse APLV sin realización de PPO.

Introduction. The oral food challenge (OFC) for the diagnosis of cow's milk protein allergy (CMPA) poses risks and requires resources. Our objective was to assess conditions and complementary tests used to identify a high probability of CMPA. Population and methods. Secondary analysis of a study of patients seen at a unit of allergy between 2015 and 2018. Pre-testing probabilities associated with symptoms and their combinations and post-testing probabilities after skin prick testing and serum immunoglobulin E (IgE) levels were determined. Results. The data from 239 patients were assessed. A probability greater than 95% was observed for angioedema and a combination of urticaria and vomiting. Based on the cut-off points proposed by Calvani et al., the combination of vomiting with rhinitis, without angioedema, also exceeded 95%. Conclusion. A methodology is provided to identify patients in whom CMPA may be diagnosed without an OFC.

Proctocolite induzida por proteína alimentar - teste de provocação oral deve ser realizado para confirmar o diagnóstico de alergia ao leite de vaca em neonatos? / Induced proctocolitis - oral food challenge should be done to confirm the diagnosis of cow's milk allergy in neonates?

ABSTRACT Background: Suspicion of food protein-induced proctocolitis based on empirical understanding of rectal bleeding can lead to misdiagnosis. Objective: to verify clinical and evaluative characteristics of patients who presented neonatal rectal bleeding and were on a restricted cow's milk diet. Methods: A cross-sectional retrospective study included patients followed up in a tertiary care center, who presented rectal bleeding in the neonatal period. The analyzed data included gender, gestational age, type of delivery, use of antibiotics during the last trimester of pregnancy, use of parenteral nutrition before the first manifestation, use of mechanical ventilation, initial clinical manifestations associated with rectal bleeding, diet before the first manifestation, period of elimination diet, oral food challenge (OFC) results and symptoms presented in cases of positive OFC. Fisher's exact test and Mann-Whitney test were used to analyze the data. The level of significance was set to 5%. Results: Forty-two patients were selected: 30 preterm infants, 34 cesarean deliveries, 10 exclusively breastfed patients before rectal bleeding. Median age at OFC was 6.3 months old. Median of length of the elimination period before OFC was 5.9 months. OFC was negative in 33/42 (79%) patients and positive in 9/42 (21%). There was no association between OFC results and the evaluated data. The main symptom observed in patients with positive OFC was blood in stools. Conclusion: OFC was negative in most cases of suspected cow's milk allergy due to rectal bleeding in neonates, most of them with a history of prematurity.

RESUMO Contexto: A suspeita de proctocolite induzida por proteína alimentar (PCIPA) com base na compreensão empírica de sangramento retal pode levar a diagnósticos equivocados. Objetivo Verificar as características clínicas e evolutivas de pacientes que apresentavam sangramento retal neonatal e faziam uso de dieta restrita com leite de vaca. Métodos: Estudo transversal retrospectivo com pacientes acompanhados em um centro terciário, que apresentaram sangramento retal no período neonatal. Os dados analisados incluíram: sexo, idade gestacional, tipo de parto, uso de antibióticos no último trimestre da gravidez, uso de nutrição parenteral antes da primeira manifestação, uso de ventilação mecânica, manifestações clínicas iniciais associadas ao sangramento retal, dieta antes da primeira manifestação, período de dieta de eliminação, resultados do teste de provocação oral (TPO) e sintomas apresentados em casos de TPO positivo. O teste exato de Fisher e o teste de Mann-Whitney foram usados para analisar os dados. O nível de significância adotado foi de 5%. Resultados: Quarenta e dois pacientes foram selecionados: 30 prematuros, 34 partos cesáreos, 10 pacientes amamentadas exclusivamente antes do sangramento retal. A idade média na ocasião do TPO foi de 6,3 meses. A mediana da duração do período da dieta de eliminação antes do TPO foi de 5,9 meses. O TPO foi negativo em 33/42 (79%) pacientes e positivo em 9/42 (21%). Não houve associação entre os resultados do TPO e os dados avaliados. O principal sintoma observado em pacientes com TPO positivo foi sangue nas fezes. Conclusão: O TPO foi negativo na maioria dos casos de suspeita de alergia ao leite de vaca devido a sangramento retal em neonatos, a maioria deles com história de prematuridade.

Cow's milk allergy immunoglobulin E-mediated: intake of proteins and amino acids

SUMMARY OBJECTIVE: Children with cow's milk allergy may be at nutritional risk due to the lower intake of nutrients, such as protein, calcium, and vitamin A, which are present in cow's milk. The objective was to evaluate children's diets with Children with cow's milk allergy compared with healthy controls as well as to compare the intake of proteins and amino acids from the diet followed by Children with cow's milk allergy who consume special infant formula or plant-based dairy alternatives with Children with cow's milk allergy who do not consume special infant formula or plant-based dairy alternatives. METHODS: Through a cross-sectional controlled study, the dietary intake of 57 children (27 with immunoglobulin E-mediated Children with cow's milk allergy and 30 healthy controls) was evaluated. Using 24-h nutritional recalls, the total energy intake value, macronutrients, and amino acids were calculated. RESULTS: No statistically significant difference was found between the Children with cow's milk allergy group and healthy controls for the intake of proteins and amino acids. However, the Children with cow's milk allergy do not consume special infant formula or plant-based dairy alternatives group had a lower protein (g/kg) and branched-chain amino acid (mg/kg) intake than the Children with cow's milk allergy consume special infant formula or plant-based dairy alternatives group. CONCLUSIONS: The Children with cow's milk allergy group achieved the recommendations for the intake of proteins and amino acids compared to the healthy control group. However, the Children with cow's milk allergy do not consume special infant formula or plant-based dairy alternatives group had a lower intake of protein (g/kg) and branched-chain amino acid (mg/kg) than the Children with cow's milk allergy consume special infant formula or plant-based dairy alternatives group.

Evaluation of the complementary feeding practices, dietary intake, and nutritional status of infants on a cow's milk protein elimination diet

Abstract Objective: To evaluate the complementary feeding practices, food intake, and nutritional status of infants on a cow's milk protein elimination diet. Methods: A cross-sectional and observational study was conducted to compare infants aged 4-18 months who were on a cow's milk protein elimination diet with a control group of healthy infants without any dietary restrictions. General information on the child's health, demographic data, and food consumption were collected. Results: The study included 96 infants in the elimination diet group and 99 in the control group. In the elimination diet group, the median age (in months) of introduction of solid foods (5.0 × 4.0; p < 0.001) and water (5.5 × 4.0; p < 0.05) was later, consumption of soft drinks and industrialized cookies was less frequent (p < 0.05), and a lower index of complementary feeding inadequacies (2.75 × 3.50; p < 0.001) was observed. The elimination diet group presented lower individual values of Z scores for weight/age, weight/height, and body mass index/age, although they were fed with higher amounts of energy (117.4 × 81.3 kcal/kg of weight; p < 0.001) and macro-and micronutrients, except for vitamin A. In the elimination diet group, breast milk and its substitutes contributed to more than 67% of energy intake. Although calcium consumption was a deficit in 31.5% of the infants, none received supplementation. Conclusion: Infants on an elimination diet presented more adequate complementary feeding practices and higher nutritional intake, despite lower body weight values.

Ebook como tecnologia educacional no ensino do cuidado seguro da criança com alergia à proteína do leite de vaca e demais alergias no ambiente escolar / Ebook as an educational technology in teaching safe care for children with cow's milk protein allergy and other allergies in the school environment

Introdução: Segundo a Organização Mundial de Saúde, 35% da população brasileira possui algum tipo de alergia, e os principais tipos de alergia são as alergias alimentares. Estudos da Associação Brasileira de Alergia e Imunologia afirmam que entre 6% e 8% das crianças e entre 2 e 3% dos adultos têm alergias alimentares (AA) e dentre todas, a alergia à proteína do leite de vaca é a causa mais comum de alergia alimentar em crianças e adolescentes. Objetivo geral: Desenvolver tecnologias educacionais, com ênfase na produção de um E-book como ferramenta pedagógica para embasar o ensino à distância do cuidado seguro da criança com alergia à proteína do leite de vaca e demais alergias, para a formação profissional dos enfermeiros e profissionais de educação. Objetivos específicos: 1- Analisar as publicações nacionais e internacionais existentes sobre a gestão do cuidado seguro da criança alérgica à proteína do leite de vaca com risco de anafilaxia no ambiente extra-hospitalar. 2- Identificar o conhecimento dos graduandos de enfermagem sobre a gestão do cuidado seguro da criança com alergia. 3-Apresentar a elaboração e a aplicação de uma oficina para o ensino de acadêmicos de enfermagem, com a construção de um Plano de Ação. 4- Estruturar um curso na modalidade à distância para o ensino de todos os profissionais que atuam nas escolas. 5- Produzir e validar um E-book como material didático para o embasamento do curso na modalidade à distância. 6- Propor um Plano de Intervenção para o Cuidado Seguro na formação profissional dos enfermeiros e para os profissionais de educação. Método: Trata-se de uma pesquisa do tipo aplicada de natureza interventiva com desenvolvimento de tecnologias educacionais baseadas no método Design Thinking, ou seja, centradas no ser humano. A coleta de dados se deu durante uma oficina pedagógica, que foi estruturada com base na Metodologia da Problematização, onde foi aplicado um Pré e Pós-teste, utilizando um questionário semiestruturado, autoaplicável, composto por questões fechadas. Também foi elaborado pelos participantes um Plano de Ação abordando a temática referente à segurança da criança alérgica à proteína do leite no ambiente escolar. A partir desta oficina e de uma revisão prévia, estruturou-se um E-book como material didático do curso na modalidade à distância, que se pretende aplicar posteriormente a este estudo. O E-book foi validado por juízes especialistas através de um instrumento composto por vinte e dois itens, divididos em três blocos para avaliação da tecnologia educacional, adaptado da ferramenta proposta por TEIXEIRA (2011). Resultados: Participaram da oficina pedagógica 16 acadêmicos de enfermagem. Observou-se que 75% (12) referiram ter tido a escola como campo de estágio e 25,0% (4) disseram não ter passado ainda por uma escola no estágio curricular. Dentre os estudantes, 56,25% (9) disseram conhecer o Programa Saúde na Escola e 43,75% (7) não conhecem esta Política Pública. Quando indagados sobre se conseguiam correlacionar os conteúdos de segurança do paciente com o ambiente escolar, 62,5% (10) disseram que sim e 37,5% (6) afirmaram não conseguir. Entretanto, 100% (16) deles reconheceram que a criança com alergia ao leite de vaca está sujeita a riscos na escola. Conclusões: Constatou-se que o objetivo da oficina pedagógica foi cumprido. Foram construídos conhecimentos de forma coletiva, os participantes puderam sentir e visualizar a situação-problema apresentada, entendendo o papel e a importância de cada ator neste cenário. Discutiu-se como o enfermeiro pode atuar e ser o profissional de saúde responsável pelo planejamento das ações de gestão do cuidado da criança com alergia à proteína do leite de vaca e demais alergias, e agir na elaboração e na implementação de estratégias que possam propiciar um ambiente escolar com um mínimo aceitável de riscos às crianças. O uso da metodologia da Problematização em combinação com ferramentas de gestão se mostrou satisfatório e pode ser aplicado em diferentes contextos de cuidado em enfermagem. Sugere-se ampliar a oportunidade de se trabalhar conteúdos de segurança do paciente, em todas as disciplinas assistenciais do Currículo de Enfermagem, para que se aprenda a identificar os riscos, medir o dano, compreender as causas, identificar as soluções, avaliar o impacto e transpor a evidência em cuidados mais seguros. Como proposta de continuidade deste projeto, almeja-se a implementação de um curso na modalidade de ensino a distância com suporte do E-book Cuidado Seguro da criança com alergia alimentar no ambiente escolar, já validado por juízes especialistas.

Introduction: According to the World Health Organization, 35% of the Brazilian population has some type of allergy, and the main types of allergy are food allergies. Studies by the Brazilian Allergy and Immunology Association state that between 6% and 8% of children and between 2 and 3% of adults have food allergies (AA). And among all, cow's milk protein allergy is the most common cause of food allergy in children and adolescents. General objective: To develop educational technologies, with emphasis on the production of an Ebook as a pedagogical tool to support the distance education of the safe care of children with allergies to cow's milk protein and other allergies, for the professional training of nurses and education professionals. Specific objectives: 1- To analyze existing national and international publications on the management of safe care for children allergic to cow's milk protein at risk of anaphylaxis in the out-of-hospital environment. 2- Identify the knowledge of nursing students on the safe care management of children with allergies. 3-To present the elaboration and application of a workshop for teaching nursing students, with the construction of an Action Plan. 4- Structuring a distance learning course for the teaching of all professionals working in schools. 5- Produce and validate an Ebook as teaching material to support the distance learning course. 6- Propose an Intervention Plan for Safe Care in the professional training of nurses and for education professionals. Method: This is an applied research of an interventional nature with the development of educational technologies based on the Design Thinking method, that is, centered on the human being. Data collection took place during a pedagogical workshop, which was structured based on the Problematization Methodology, where a Pre and Post-test was applied, using a semi-structured, self-administered questionnaire, consisting of closed questions. Participants also drew up an Action Plan addressing the issue related to the safety of children allergic to milk protein in the school environment. From this workshop and from a previous review, an Ebook was structured as didactic material for the course in the distance mode, which is intended to be applied later to this study. The Ebook was validated by expert judges through an instrument composed of twenty-two items, divided into three blocks for the assessment of educational technology, adapted from the tool proposed by TEIXEIRA (2011).Results: 16 nursing students participated in the pedagogical workshop. It was observed that 75% (12) reported having had the school as an internship field and 25.0% (4) said they had not yet gone through a school in the curricular internship. Among the students, 56.25% (9) said they knew the PSE and 43.75% (7) did not know this Public Policy. When asked if they could correlate patient safety content with the school environment, 62.5% (10) said yes and 37.5% (6) said they could not. However, 100% (16) of them recognized that the child with a cow's milk allergy is subject to risks at school. Conclusions: It was found that the objective of the pedagogical workshop was fulfilled. Knowledge was built collectively, participants could feel and visualize the problem situation presented, understanding the role and importance of each actor in this scenario. It was discussed how the nurse can act and be the health professional responsible for planning the management actions of child care with allergies to cow's milk protein and other allergies, and act in the design and implementation of strategies that can provide a school environment with an acceptable minimum risks to children. The use of the problematization methodology in combination with management tools, proved to be satisfactory, and can be applied in different contexts of nursing care. It is suggested to expand the opportunity to work on patient safety content, in all the care disciplines of the Nursing Curriculum, so that one learns to identify the risks, measure the damage, understand the causes, identify the solutions, evaluate the impact and transpose the evidence into safer care. As a proposal for the continuity of this project, the aim is to implement a distance learning course supported by the Ebook Safe Care of children with food allergy in the school environment, already validated by expert judges.

Recomendaciones sobre la utilización de las fórmulas infantiles con proteína aislada de soya en la alimentación del lactante. Documento de posición basado en la evidencia / Recommendations on the use of infant formulas with isolated soy protein in infant feeding. Evidence-Based Position Paper

Antecedentes: Las fórmulas a base de proteína de soya (FBPS) se han utilizado desde hace tiempo como una alternativa para lactantes con requerimientos nutricionales especiales. Sin embargo, las indicaciones médicas para su uso, su alergenicidad, seguridad y eficacia aún son controvertidas. Objetivo: Presentar recomendaciones del uso de FBPS basadas en la literatura existente. Métodos: Se realizó la consulta de revisiones sistemáticas y guías de práctica clínica, por medio de algoritmos de búsqueda validados, y sistemas como AGREE (Appraisal of Guidelines for REsearch and Evaluation) II y PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Para la elaboración de las recomendaciones clínicas se analizaron y discutieron los tópicos de mayor importancia, por parte de los investigadores responsables y el grupo de expertos del desarrollo de un documento de posición. Se evaluó la calidad de la evidencia utilizando el sistema GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Resultados: Se encontraron distintos reportes con calidad de evidencia variable que sustentan la eficacia de las FBPS en el manejo de la alergia a la proteína de la leche de vaca y en la tolerancia digestiva del lactante, así como su baja alergia cruzada en comparación a la leche de vaca y otras fórmulas. También se encontraron otros estudios que indican la seguridad de las FBPS sobre distintos parámetros nutricionales, inmunitarios y de desarrollo. Existe además evidencia que demuestra que las FBPS tienen ventajas importantes en cuestión de costo-beneficio, palatabilidad y efectos sobre la microbiota intestinal, en comparación con otras fórmulas. Conclusiones: Aunque existe evidencia limitada para recomendar su utilización en los trastornos digestivos funcionales, las FBPS tienen un perfil de seguridad adecuado y continúan siendo una opción válida para la alimentación del lactante.

Abstract Background: Soy infant formulas (SIF) have long been used as an alternative for infants with special nutritional requirements. However, the medical indications for their use, their allergenicity, safety and efficacy are still controversial. Objective: To present recommendations for the use of SIF based on the existing literature. Methods: We consulted systematic reviews and clinical practice guides, through validated search algorithms, and systems such as Appraisal of Guidelines for REsearch and Evaluation (AGREE)II and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For the elaboration of the clinical recommendations, the most important topics were analyzed and discussed by the responsible researchers and the group of experts in the development of a position paper. The quality of the evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results: Several reports with variable quality of evidence were found. They support SIF’s efficacy in the management of cow’s milk allergy and infant’s digestive tolerance, as well as its low cross allergy compared to cow’s milk and other formulas. We also found other studies that indicate the safety of SIFs on different nutritional, immune and developmental parameters. There is also evidence that demonstrates that SIFs have important advantages in terms of cost-benefit, palatability and effects on the intestinal microbiota, compared to other formulas. Conclusions: Although evidence to recommend its use in functional digestive disorders is limited, SIFs have an adequate safety profile and are still a valid option for infant feeding.

Knowledge and practice of pediatricians and nutritionists regarding treatment of cow's milk protein allergy in infants / Conhecimento e prática de pediatras e nutricionistas sobre o tratamento da alergia às proteínas do leite de vaca em lactentes

ABSTRACT Objective This study evaluated the knowledge and practices of pediatricians and nutritionists about cow's milk protein allergy in infants, with an emphasis on issues related to the exclusion diet and nutritional status. Methods A cross-sectional, descriptive study was performed with a convenience sample of 204 pediatricians and 202 nutritionists randomly invited in scientific events in the city of São Paulo, from November 2014 to March 2016. Results Between 1.5% and 21.0% of respondents indicated inadequate products for the treatment of cow's milk protein allergy, including goat's milk, beverages or juices based on soy extract, lactose-free milk formula and partially hydrolyzed formula. The daily calcium recommendation for children between zero and 36 months of age was correctly indicated by 27.0% of pediatricians and 46.0% of nutritionists (p=0.001). Additionally, 96.1% of pediatricians and 82.7% of dietitians (p<0.001) provided guidance on about labels of industrialized products. Conclusion Pediatricians and nutritionists present gaps in knowledge about cow's milk protein allergy treatment in infants and educational strategies that increase the knowledge of the professionals are important for the management of cow's milk protein allergy.

RESUMO Objetivo Este estudo avaliou o conhecimento e práticas de pediatras e nutricionistas sobre alergia às proteínas do leite de vaca em lactentes, com ênfase em questões relacionadas à dieta de exclusão e ao estado nutricional. Métodos Estudo transversal, descritivo, realizado com uma amostra de conveniência de 204 pediatras e 202 nutricionistas, convidados aleatoriamente em eventos científicos na cidade de São Paulo, de novembro de 2014 a março de 2016. Resultados Entre 1,5% e 21,0% dos entrevistados indicaram produtos inadequados para o tratamento da alergia às proteínas do leite de vaca, incluindo leite de cabra, bebidas ou sucos à base de extrato de soja, fórmula de leite sem lactose e fórmula parcialmente hidrolisada. A recomendação diária de cálcio para crianças entre zero e 36 meses de idade foi corretamente indicada por 27,0% de pediatras e 46,0% de nutricionistas (p=0,001). Além disso, 96,1% dos pediatras e 82,7% dos nutricionistas (p<0,001) forneceram orientação sobre os rótulos dos produtos industrializados. Conclusão Pediatras e nutricionistas apresentam lacunas no conhecimento sobre o tratamento da alergia às proteínas do leite de vaca em lactentes. Estratégias educacionais que aumentam o conhecimento dos profissionais são importantes para o gerenciamento da alergia às proteínas do leite de vaca.

Estudio de validez diagnóstica de la prueba de hemorragia oculta fecal en lactantes con proctocolitis alérgica inducida por proteína alimentaria / Diagnostic validity of fecal occult blood test in infants with food protein-induced allergic proctocolitis

Resumen: Introducción: La proctocolitis alérgica inducida por proteína alimentaria (PCA) es la forma más fre cuente de alergia alimentaria no mediada por IgE. El diagnóstico se realiza por prueba de provocación oral, sin embargo, no existe una prueba diagnóstica no invasiva para su diagnóstico. Frecuentemente en Chile se utiliza la prueba de hemorragia oculta fecal (PHOF) para confirmar PCA, pero no hay estudios que respalden su indicación. Objetivo: Determinar la validez diagnóstica de la PHOF en la evaluación de lactantes con PCA. Pacientes y Método: Estudio de casos y controles con recluta miento prospectivo de lactantes con rectorragia y sospecha de PCA y lactantes sanos, en quienes se realizó una PHOF. Se indicó dieta de exclusión a los casos y luego se confirmó diagnóstico de PCA mediante contraprueba. Resultados: Se incluyó a 25 casos y 29 controles sin diferencias signi ficativas en edad, sexo, tipo de parto, alimentación o edad materna. Los casos presentaron con mayor frecuencia comorbilidades alérgicas, uso de medicamentos y antecedentes familiares de alergia. La PHOF fue positiva en 84% de casos y en 34% de controles (p<0,001). La sensibilidad de la PHOF para diagnosticar PCA fue 84%, especificidad 66%, valor predictivo positivo 68% y valor predictivo nega tivo 83%. El área bajo la curva ROC fue de 0,75 (IC 95% 0,61-0,88). Conclusiones: Si bien la PHOF tiene sensibilidad adecuada para detectar PCA en lactantes con rectorragia, resulta alterada en más de un tercio de lactantes sanos por lo que no se recomienda su uso habitual para el diagnóstico de PCA.

Abstract: Introduction: Food protein-induced allergic proctocolitis (FPIAP) is the most frequent presenta tion of non-IgE mediated food allergy (FA). The diagnosis is made by oral food challenge, however, non-invasive diagnostic tests are not available. In Chile, the fecal occult blood test (FOBT) is fre quently used to confirm FPIAP, however, there are no studies that support this practice. Objective: To establish the diagnostic validity of FOBT in the evaluation of infants with FPIAP. Patients and Method: Case-control study with prospective recruitment of infants with rectal bleeding and suspicion of FPIAP, and controls were healthy infants, in whom the FOBT was conducted. All cases underwent an elimination diet, after which the diagnosis of FPIAP was confirmed by oral food cha llenge. Results: 25 cases and 29 controls were included without significant differences in age, gen der, type of delivery, feeding, and maternal age. The cases had higher rates of allergic comorbidities, medication use, and family history of allergy. The FOBT was positive in 84% of cases and in 34% of controls (p < 0.001). The sensitivity of the FOBT for the diagnosis of FPIAP was 84%, specificity was 66%, positive predictive value 68%, and the negative predictive value 83%. The area under the ROC curve was 0.75 (CI 95% 0.61-0.88). Conclusions: Although the FOBT has an adequate sensitivity to diagnose FPIAP in infants with rectal bleeding, this test had abnormal results in more than a third of healthy infants. Therefore, the routine use of FOBT is not recommended for the diagnosis of FPIAP.

Ksheeralasaka Vis-à-vis Cow’s Milk Allergy: A Critical Review

Ksheeralasaka is a multi-system disease of the breast-fed child caused by Sannipataja-stanya-dushti (breast milk vitiated by all the Tridoshas). A proper understanding of the condition is not available and it is confused with lactose intolerance and cow’s milk allergy. Hence a thorough review of Ksheeralasaka and its management in the light of Ayurvedic and modern principles is intended in this paper so that suitable therapies can be selected. Ksheera denotes breast milk and Alasaka is a type of Ajeerna (indigestion), a condition called Ama caused by Agnimandya or weak digestive/metabolic power. Thus Ksheeralasaka is Ajeerna or indigestion in the infant caused by intake of vitiated breast milk. Ksheeralasaka is most similar to non-IgE-mediated cow’s milk protein allergy and is also comparable with food allergies caused by egg, peanuts, etc. Lactose intolerance and lactose overload can also co-occur with cow’s milk protein allergy or food allergies. Being a disease of Ama and Stanyadushti, Apatarpana (depletion) in the form of Sodhana (purification) and Stanyasodhana (purification of breast milk) are the treatments to be adopted. Langhana or fasting is sufficient if Ama is mild, Langhana and Pachana (digestives) are needed if it is moderate and Sodhana (purification) is needed if severe. Vamana for mother and child purifies the gut and expels the allergens ingested. Breast milk purifiers and anti-diarrhoeals are judiciously advised for the mother and the child respectively. Advice regarding feeding practices can help reduce symptoms of lactose overload that may co-occur.

Uso de leite processado em altas temperaturas por paciente com alergia ao leite de vaca - relato de caso / Use of milk processed at high temperatures by a patient with cow's milk allergy: case report

Objetivo: Relatar a evolução clínica de um escolar com alergia ao leite de vaca (ALV) que fez uso de leite de vaca processado em altas temperaturas (LVPAT). Descrição: H.B.M., sexo masculino, 7 anos, com ALV IgE mediada diagnosticada com 1 ano e 3 meses. Aos 2 anos foi submetido a teste de provocação oral (TPO) aberto para leite de vaca (LV) in natura, evoluindo com urticária, congestão nasal e vômito após a primeira dose (1 mL). Mãe relatou alguns episódios de exposição acidental ao LV acompanhados de sintomas. As Imunoglobulinas E para LV e frações mantiveram-se elevadas (IgE leite total: 4,69 KU/L) até os 6 anos, quando a criança realizou TPO com LVPAT, sob a forma de bolo, evoluindo sem intercorrências. Passou a consumir diariamente uma porção do bolo contendo leite processado durante 6 meses. Aos 7 anos e com IgEs específicas mais baixas (IgE específica leite total: 2,2 KU/L), realizou TPO com LV in natura sem sintomas, sendo liberado na dieta. Comentários: O uso do leite de vaca processado em altas temperaturas em pacientes com ALV IgE mediada é uma estratégia promissora com impacto na tolerância futura ao alimento, tendo resultados favoráveis com ênfase na qualidade de vida e inclusão social. No entanto, vale ressaltar a importância da avaliação individualizada dos pacientes e a segurança da equipe na aplicação desses protocolos, além de levar em consideração que a alergia pode ser transitória, mesmo sem o uso do leite processado.

Objective: To report the clinical evolution of a school-age boy with cow's milk allergy CMA) who made use of cow's milk processed at high temperatures (CMPHT). Description: H.B.M., male, 7 years old, was diagnosed with IgE-mediated CMA at 1 year and 3 months of age. At 2 years of age, the patient underwent an open oral food challenge for raw cow's milk (CM) and developed urticaria, nasal congestion and vomiting after the first dose (1 mL). The mother reported some episodes of accidental exposure to CM, accompanied by symptoms. Specific IgEs against CM and its fractions remained elevated (total cow's milk: 4.69 KU/L) until 6 years of age, when the patient underwent a new oral food challenge for CMPHT, in the form of a cake, without symptoms. He then began to consume a portion of cake containing baked milk daily, for 6 months. At the age of 7 and with lower levels of specific IgEs (total cow's milk: 2.2 KU/L), he underwent another oral food challenge for raw CM, without symptoms. An unrestricted diet was then authorized. Comments: The use of cow's milk processed at high temperatures in patients with IgE-mediated cow's milk allergy is a promising strategy, with impact on future food tolerance, favorable results, with emphasis on quality of life and social inclusion. However, an individualized assessment of each patient is extremely important, as is the confidence of the team while applying these protocols. It should be taken into consideration that the allergy may be transient even without the use of processed milk.

Cow's milk oral immunotherapy in real life: 8-year long-term follow-up study

BACKGROUND: Oral immunotherapy (OIT) has been recognized as a promising treatment for severe and long-lasting cow's milk (CM) allergy. Once maintenance has been achieved, patients should maintain daily intake of CM to ensure desensitization. Clinical experience concerning long-term follow-up is scarce. OBJECTIVE: The authors aimed to assess long-term efficacy and safety of a maintenance phase of OIT in real life. METHODS: Prospective study of all children and adolescents, who underwent CM-OIT and were subsequently followed at our allergy center on maintenance dose (200 mL daily) for at least 36 months after reaching the maintenance phase (from 2009 to 2016). RESULTS: Forty-two patients were enrolled: 60% male, 36% with history of anaphylaxis and 57% with asthma. The median time of follow-up was 69 months (range, 39–105 months) and the median age at the last clinical evaluation was 13 years (range, 6–23 years). Regarding adherence to the protocol: 92% are on free diet (at least 200 mL of CM daily; 7-g protein); 14% had transient interruptions and 7% definitely withdrawn with loss of tolerance. During maintenance, 45% developed mild to severe allergic reactions, and 7% had more than 3 episodes. A positive correlation between the occurrence of allergic reactions and history of anaphylaxis (p < 0.001) was found. The coexistence of asthma was risk factor for the occurrence of allergic reactions during maintenance. CONCLUSION: This real-life study supports long-term efficacy and safety of CM-OIT. Despite daily intake, 41% had symptoms at some moment during the complete follow-up period; a total of 33 symptomatic days in patients with mean follow-up time of 67.5 months. Clinical tolerance depends on daily intake. The protective effect reached can be lost after CM withdrawal. History of anaphylaxis was a risk factor for the occurrence of allergic reactions during the maintenance phase.

Do infants with cow's milk protein allergy have inadequate levels of vitamin D? / Lactentes com alergia à proteína do leite de vaca apresentam níveis inadequados de vitamina D?

Abstract Objective: To verify whether infants with cow's milk protein allergy have inadequate vitamin D levels. Methods: This cross-sectional study included 120 children aged 2 years or younger, one group with cow's milk protein allergy and a control group. The children were recruited at the pediatric gastroenterology, allergology, and pediatric outpatient clinics of a university hospital in the Northeast of Brazil. A questionnaire was administered to the caregiver and blood samples were collected for vitamin D quantification. Vitamin D levels <30 ng/mL were considered inadequate. Vitamin D level was expressed as mean and standard deviation, and the frequency of the degrees of sufficiency and other variables, as proportions. Results: Infants with cow's milk protein allergy had lower mean vitamin D levels (30.93 vs.35.29 ng/mL; p = 0.041) and higher deficiency frequency (20.3% vs.8.2; p = 0.049) than the healthy controls. Exclusively or predominantly breastfed infants with cow's milk protein allergy had higher frequency of inadequate vitamin D levels (p = 0.002). Regardless of sun exposure time, the groups had similar frequencies of inadequate vitamin D levels (p = 0.972). Conclusions: Lower vitamin D levels were found in infants with CMPA, especially those who were exclusively or predominantly breastfed, making these infants a possible risk group for vitamin D deficiency.

Resumo Objetivo: Verificar se lactentes com alergia à proteína do leite de vaca (APLV) apresentam níveis inadequados de vitamina D. Métodos: Estudo transversal, envolveu 120 crianças de até dois anos, um grupo com APLV e outro de comparação, captadas dos ambulatórios de Gastroenterologia Pediátrica, Alergologia Pediátrica e Puericultura de um hospital universitário, no Nordeste brasileiro. Foi aplicado um formulário e foram coletadas amostras sanguíneas para a análise da vitamina D, foram considerados inadequados os níveis < 30 ng/mL. Níveis de vitamina D foram expressos em média e desvio padrão e a frequência dos graus de suficiência e demais variáveis, em proporções. Resultados: Lactentes com APLV, quando comparados com os saudáveis, apresentaram uma menor média do nível da vitamina D (30,93 vs. 35,29 ng/mL) (p = 0,041) e maior frequência de deficiência (20,3% vs. 8,2) (p = 0,049). Maior frequência de níveis inadequados de vitamina D foi observada nas crianças com APLV que estavam em aleitamento materno exclusivo/predominante (p = 0,002). Independentemente do período de exposição solar, a frequência de um status inadequado de vitamina D foi semelhante entre os grupos (p = 0,972). Conclusões: Menores níveis de vitamina D foram observados em lactentes com APLV, especialmente naqueles em aleitamento materno exclusivo/predominante, que configura esse como um possível grupo de risco para essa deficiência.

Proteomics: a tool to develop novel diagnostic methods and unravel molecular mechanisms of pediatric diseases / Proteómica: una herramienta para desarrollar nuevos métodos de diagnóstico y descifrar mecanismos moleculares de enfermedades pediátricas

Abstract: Proteomics is the study of the expression of changes and post-translational modifications (PTM) of proteins along a metabolic condition either normal or pathological. In the field of health, proteomics allows obtaining valuable data for treatment, diagnosis or pathophysiological mechanisms of different illnesses. To illustrate the aforementioned, we describe two projects currently being performed at the Instituto Nacional de Pediatría: The immuno-proteomic study of cow milk allergy and the Proteomic study of childhood cataract. Cow's milk proteins (CMP) are the first antigens to which infants are exposed and generate allergy in some of them. In Mexico, the incidence of CMP allergy has been estimated at 5-7%. Clinical manifestations include both gastrointestinal and extra-gastrointestinal symptoms, making its diagnosis extremely difficult. An inappropriate diagnosis affects the development and growth of children. The goals of the study are to identify the main immune-reactive CMP in Mexican pediatric population and to design more accurate diagnostic tools for this disease. Childhood cataract is a major ocular disease representing one of the main causes of blindness in infants; in developing countries, this disease promotes up to 27% of cases related to visual loss. From this group, it has been estimated that close to 60% of children do not survive beyond two years after vision lost. PTM have been pointed out as the main cause of protein precipitation at the crystalline and, consequently, clouding of this tissue. The study of childhood cataract represents an outstanding opportunity to identify the PTM associated to the cataract-genesis process.

Resumen: La proteómica estudia los cambios de expresión y post-traduccionales (PTM) de las proteínas durante una condición metabólica normal o patológica. En el campo de la salud, la proteómica permite obtener datos útiles para el tratamiento, diagnóstico o en la fisiopatología de diferentes enfermedades. Para ilustrar lo anterior, describimos dos proyectos realizados en el Instituto Nacional de Pediatría: El estudio inmunoproteómico de la alergia a la leche y el estudio proteómico de la catarata infantil. Las proteínas de leche bovina (PLB) son los primeros antígenos a los que se exponen los infantes y un porcentaje de ellos generará alergias. En México, se estima que la incidencia de alergias a las PLB es del 5-7%. Las manifestaciones clínicas incluyen tanto síntomas gastrointestinales como extra-gastrointestinales, dificultando su diagnóstico. Un mal diagnóstico afecta el desarrollo y crecimiento del infante. Los objetivos del estudio son identificar las principales PLB inmunoreactivas en población infantil mexicana y diseñar herramientas diagnósticas más precisas para esta patología. La catarata infantil es una enfermedad ocular que representa una de las causas principales de ceguera infantil; en países subdesarrollados genera cerca del 27% de casos relacionados con pérdida visual. De este grupo, se estima que cerca del 60% de los infantes no sobreviven más allá de los dos años después de perder la visión. Se señala a las PTM como las responsables de la precipitación de proteínas del cristalino y, por tanto, de su opacidad. El estudio de la catarata infantil representa una oportunidad para identificar las PTM vinculadas con la cataratogénesis.

Oral Food Desensitization in Children With IgE-Mediated Cow's Milk Allergy: Immunological Changes Underlying Desensitization

PURPOSE: This study aimed to evaluate the safety and efficacy to induce clinical desensitization to cow's milk (CM) of an oral immunotherapy (OIT) protocol in a pediatric population with cow's milk allergy (CMA). In addition, the immune responses against β-casein, of peripheral blood mononuclear cells (PBMCs) from CMA patients, before and after the protocol were evaluated and compared to a nonallergic population. METHODS: A group of 20 children with IgE-mediated CMA and 15 nonallergic children were recruited. Allergic subjects underwent an OIT protocol based on weekly doses of commercial semi-skimmed ultra-high temperature treated (UHT) CM, followed by a maintenance phase. Immune profiles and changes in all subjects were investigated by measuring Th1, Th2, and Treg cytokines, transcription factors, and specific IgE and IgG4 levels. RESULTS: The CM-OIT protocol enabled to desensitize 70% of the allergic patients. Successful OIT was accompanied by significant increases in casein-specific IgG4 levels, together with a reduction in the concentration of antigen-specific IgE and in IL-5, IL-13, and IL-10 production by β-casein-stimulated PBMCs. Baseline significant differences observed between allergic and nonallergic children in IL-13 and IL-5 levels were no longer found once the protocol had finished. CONCLUSIONS: The OIT protocol was safe and effective in inducing milk desensitization in 70% of the children with CMA, leading to alterations in their immune profiles toward a nonallergic phenotype.

A Case of Persistent Cow's Milk Allergy Accompanying Atopic Dermatitis / 대한피부과학회지

No abstract available.

Características clínicas y manejo de lactantes menores de 1 año con sospecha de alergia a proteína de leche de vaca / Clinical characteristics and management of infants less than 1-year-old suspected with allergy to cow's milk protein

Introducción: La alergia a proteína de leche de vaca (APLV) es frecuente en lactantes (2-5% en < 1 año). Tiene múltiples formas de presentación y un amplio diagnóstico diferencial, por lo que es relevante confirmar el diagnóstico. El estándar de oro del diagnóstico es el test de provocación oral (TPO), que en la práctica no siempre se realiza. En Chile hay escasa literatura respecto a esta entidad. Objetivo: Describir características demográficas, clínicas y manejo de lactantes < 1 año con sospecha de APLV. Pacientes y Método: Estudio retrospectivo en menores de 1 año atendidos por sospecha de APLV entre 2009-2011. Se registraron datos demográficos, historia perinatal, antecedentes de atopia, alimentación al momento del diagnóstico, síntomas de sospecha de APLV, estudios realizados para su confirmación, y respuesta a tratamiento. Se consideró como estándar de diagnóstico la respuesta a la dieta y la contraprueba. Se definió como respuesta a la dieta la ausencia de los síntomas atribuidos a la APLV al menos 4 semanas desde el cambio de leche. Se realizó estadística descriptiva mediante programa Epiinfo™. Resultados: Se incluyeron 106 lactantes, 51% varones, 80% recién nacidos de término, 74% con al menos un progenitor atópico, 34% con alguno de los padres o algún hermano con alergia alimentaria. La mediana de edad al inicio fue 1,5 meses (rango: 1,5-2 m). El 15% recibió fórmula desde el período neonatal y el 50% antes del tercer mes. Los síntomas más frecuentes fueron: vómitos (63%), cólicos (50%) y rectorragia (40%); el 61% presentó ≥ 2 síntomas al comienzo. Solo en el 34% se hizo TPO, en el resto se evaluó la respuesta a la dieta de exclusión y se realizaron exámenes. La realización de exámenes no cambió la conducta. Tratamiento: 43% lactancia materna con dieta de exclusión, 24% solo fórmula extensamente hidrolizada, 26% solo fórmula aminoacídica y 7% otros. Conclusión: Las características demográficas y antecedentes de los pacientes concuerdan con lo descrito en la literatura extranjera. El inicio clínico fue precoz, predominando los síntomas digestivos. Se realizaron exámenes en una proporción alta de pacientes, sin contribuir a un cambio de conducta; el TPO fue subutilizado como herramienta diagnóstica.

Introduction: Cow's milk protein allergy (CMPA) is highly prevalent in infants (2-5%). It has a wide clinical spectrum, and confirmation through an oral food challenge (OFC) is relevant for its differential diagnosis. Information on this topic is scarce in Chile. Objective: To describe the demographic and clinical features of infants with suspected CMPA. Patients and Method: A retrospective study of patients < 1 year-old, treated for suspected CMPA between 2009 and 2011. Demographic data, symptoms of atopy, nutrition at the time of diagnosis, CMPA symptoms, diagnostic studies, and response to treatment were recorded. Diet response at least 4 weeks after milk modification, and clinical behavior when suspected foods were added back to the diet were considered standard diagnostic criteria. Descriptive statistics were performed using Epiinfo ™ software. Results: The study included 106 infants, of whom, 51% male, 80% term newborns, 74% with ≥ 1 atopic parent, and 34% with ≥ 1 parent/sibling with food allergy. The median age at onset of symptoms was 1.5 months (range 1.5-2 m). Almost half (46%) were breast-feeding ≥ 6 m, with 15% receiving formula milk since the neonatal period, and 49% before the third month. Common symptoms were: vomiting (63%), colic (49%), and bleeding on passing stools (41%). No anaphylaxis was identified, and 61% had ≥ 2 symptoms at debut. Only 34% were subjected to OFC. The most frequently requested tests were, test patch (43%), prick test (40%), and blood in stools (37%). Treatment: 43% breast feeding with exclusion diet, 24% extensively hydrolysed formula, 26% amino acid formula, and 7% others. Conclusion: Demographic characteristics and risk factors were similar to those previously described in international literature. Clinical presentation was early in life, and digestive symptoms predominated. OFC was underused for diagnosis, and most of the tests requested did not change management.

The ingestion of cow's milk formula in the first 3 months of life prevents the development of cow's milk allergy

BACKGROUND: IgE-mediated cow's milk allergy (CMA) is one of the most common food allergies in infants. It is still controversial whether the early introduction of cow's milk formula (CMF) prevents the development of CMA. OBJECTIVE: We aimed to evaluate the duration and frequency of CMF ingestion as compere with exclusive breast-fed for preventing CMA in high-risk infants. METHODS: We enrolled the patients diagnosed with hen's egg allergy by an oral food challenge. A questionnaire was completed by the caregivers of the patients regarding the timing of introduction and discontinuation of CMF, and the frequency of CMF ingestion. Based on the information, we analyzed the relationship between the duration and frequency of CMF ingestion and the development of CMA at 3–24 months of age. RESULTS: Three hundred seventy-four patients were analyzed; 171 were diagnosed with CMA (45.7%). The analyzed patients (n = 374) were categorized into the following subgroups: exclusively breast-fed (breast-fed group, n = 75); discontinued ingestion of CMF before 3 months of age (temporary group, n = 177); continuous ingestion of CMF, but not daily, up to 3 months of age (nondaily group, n = 47); continuous ingestion of CMF at least once daily (daily group, n = 75). The incidence of developing CMA between the breast-fed group and temporary group did not show any statistical difference. Nondaily group and daily group had significantly lower incidence of developing CMA in comparison to the breast-fed group (nondaily group odds ratio 0.43; p = 0.02, daily group odds ratio 0.11; p < 0.001). CONCLUSION: Ingestion of CMF during the first 3 months of life might prevent the development of CMA in high-risk infants.

INFLUENCIA DEL TIPO DE ALIMENTACIÓN EN EL DESARROLLO DE LA ALERGIA A LA LECHE DE VACA. FACTORES INVOLUCRADOS EN EL PROCESO POR EL CUAL SE ADQUIERE LA ENFERMEDAD / Infl uence of the type of feeding in the development of cow's milk allergy. Factors involved in the process by which the disease is acquired

Antecedentes. Los resultados de las investigaciones sobre la historia natural de la alergia a la leche de vaca (ALV) no han provisto aún, de un cuadro claro y consistente que ayude en la práctica al médico tratante. Objetivo. Identifi car los factores involucrados en el desarrollo de la enfermedad en lactantes pequeños, con el fi n de determinar perfi les específi cos e índices predictivos. Lugar de realización: Río Cuarto, Córdoba, Argentina. Diseño. Análisis observacional y retrospectivo. Población. 91 niños con diagnóstico de ALV y 91 controles, de ambos sexos, menores de 6 años. Método. Análisis de factores seleccionados de las historias clínicas, su relación individual con el diagnóstico (prueba X2, Odds Ratios, diferencias de medias) y su incidencia conjunta en la probabilidad de ser ALV para determinar perfi les (análisis de correspondencias múltiple y regresión logística). Elaboración de 3 índices predictivos basados en: odds ratios individuales, los correspondientes a la regresión logística y la identifi cación de criterios mayores y menores, con su respectiva evaluación de efectividad diagnóstica (sensibilidad, especifi cidad, valores predictivos y curva ROC). Resultados. Se encontró que la edad de inicio de los síntomas, el tipo de alimentación recibida hasta el 3er mes de vida, la exposición al humo de cigarrillo, los antecedentes alérgicos maternos y el tipo de manifestaciones clínicas con que comienza la ALV son factores que con mayor probabilidad inciden en su desarrollo. Conclusión. La utilidad de estos perfi les e índices predictivos radica en una temprana identifi cación de pacientes con riesgo de padecer ALV(AU)

Background: The results of the research on the natural history of allergy to cow's milk allergy (CMA) still have not provided a clear picture and consistent that in practice helps the attending physician. Objective: to identify the factors involved in the development of the disease in young infants, in order to determine specifi c profi les and predictive clinical indexes. Setting: Río Cuarto, Córdoba, Argentina. Design: observacional and retrospective analysis. Population: 91 children with a diagnosis of CMA and 91 controls, of both sexes, under the age of 6 years. Methods: analysis of selected factors of the clinical histories, their relationship with the individual diagnosis (test X2, Odds Ratios, differences in average) and their combined impact on the probability of being CMA to determine profi les (multiple correspondence analysis and logistic regression). Elaboration of 3 predictive indices based on: individual Odds Ratios, corresponding to the logistic regression and the identifi cation of greater and smaller criteria, with its respective evaluation of effectiveness diagnoses (predictive sensitivity, specifi city, values and ROC curve). Results: we found that the age of onset of symptoms, the type of feeding received until the 3rd month of life, exposure to cigarette smoke, the maternal allergy history and the type of clinical manifestations with that begins the CMA, are factors that most likely have an impact on its development. Conclusion: the utility of these profi les and predictive clinics indexes lies in an early identifi cation of patients at risk of CMA.(AU)