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.

Fatores preditores do desfecho do Teste de Provocação Oral na Alergia à Proteína do Leite de Vaca: in natura vs. alimentos processados / Predictors of the outcome of the Oral Food Challenge for Cow's Milk Protein Allergy: raw vs. processed foods

Objetivos: Descrever uma população de crianças com alergia à proteína do leite de vaca (APLV) IgE mediada, submetidas ao teste de provocação oral (TPO) com alimentos processados vs. in natura, e comparar características clínico-epidemiológicas e laboratoriais, avaliando preditores de desfecho ao uso dessas diferentes apresentações de proteína. Métodos: Estudo transversal realizado em ambulatório de alergia de um hospital terciário em Fortaleza, Ceará. A coleta dos dados foi realizada entre outubro de 2018 a setembro de 2019. O questionário foi preenchido com os dados epidemiológicos, clínicos e laboratoriais encontrados no prontuário; amostra total de 49 crianças, com APLV IgE mediada tolerantes ao TPO com alimentos processados ou in natura. Resultados: Na comparação das características clinico-epidemiológicas das populações tolerantes a alimentos in natura vs. processados (respectivamente), a maioria apresentou dados semelhantes, como sexo masculino (60% vs. 57,9%), etnia parda (73,3% vs. 68,4%), idade gestacional a termo (80% vs. 77,8%), sem intercorrências durante a gestação (58,3% vs. 80,0%) ou parto (70% vs. 78,9), média de idade materna (32 anos vs. 35 anos), escolaridade materna (ensino médio completo - 43,3% vs. 47,4%), idade de início dos sintomas de APLV entre 1 e 6 meses (76,7% vs. 68,4%), aleitamento materno exclusivo entre 4 e 6 meses (60% vs. 68,45%), histórico de alergia familiar alimentar (73% vs. 68,4%), sendo as principais comorbidades alérgicas as respiratórias (38,9% vs. 35,7%) e alimentares (38,9% vs. 35,7%). Em relação aos dados laboratoriais, a maioria das frações de proteína no grupo tolerante a alimentos in natura e a alimentos processados apresentou valores ≤ 10 kU/L. Foi constatado que a idade materna (p = 0,006) e a idade de introdução de fórmula complementar (p = 0.020) se correlacionam de forma estatisticamente significante no grupo de pacientes tolerantes a alimentos processados. Conclusões: Foi observado que a idade materna (p = 0,006) e a idade de introdução de fórmula complementar (p=0.020) se correlacionam de forma estatisticamente significante no grupo de pacientes tolerantes alimentos processados. Os dados laboratoriais seguiram distribuição proporcionais entre os dois grupos, com maior frequência de valores ≤ 10 kU/L para todas as frações de proteína do leite de vaca, sem significância estatística. Estudos populacionais semelhantes em populações APLV IgE mediada são importantes para caracterizar melhor esse fenótipo e otimizar ferramentas diagnósticas e protocolos de tratamento. Destaca-se também o papel da terapia baked, que auxilia na aquisição de tolerância a diferentes apresentações da PLV de forma mais breve, melhorando, portanto, a qualidade de vida desses pacientes (AU)

Objectives: To describe the population of children with IgE-mediated CMPA tolerant to processed or raw CMP in the OFC, comparing their clinical, epidemiological and laboratory characteristics and evaluating the possible predictors of outcomes associated with these different presentations of CMP. Methods: Cross-sectional study carried out in an allergy clinic of a tertiary hospital in Fortaleza, Ceará. Data collection was carried out between October 2018 and September 2019. The questionnaire was filled out with epidemiological, clinical and laboratory data found in the medical records. The total sample was composed of 49 children with IgE-mediated CMPA tolerant to processed or raw foods in the OFC. Results: The comparison of the clinical and epidemiological characteristics of populations tolerant to raw foods vs. processed (respectively) showed similarities, such as the predominance of the male gender (60% vs. 57.9%); mixed ethnicity (73.3% vs. 68.4%); delivery at term (80% vs. 77 .8%); no complications during pregnancy (58.3% vs. 80.0%) or childbirth (70% vs. 78.9); mean maternal age (32 years vs. 35 years); level of education of the mothers (complete high school - 43.3% vs. 47.4%); age of onset of CMPA symptoms between 1 and 6 months (76.7% vs. 68.4%); exclusive breastfeeding for 4 to 6 months (60% vs. 68.45%); family history of food allergy (73% vs. 68.4%); and respiratory (38.9% vs. 35.7%) and food allergies (38.9% vs. 35.7%) as the main allergic comorbidities. Regarding laboratory data, most protein fractions had values ≤ 10 kU/L in both groups. It was found that maternal age (p = 0.006) and age of introduction of formula (p = 0.020) were statistically significant in the group of patients tolerant to processed foods. Conclusions: It was observed that maternal age (p = 0.006) and age of introduction of formula (p = 0.020) were statistically significant in the group of patients tolerant to processed foods. Laboratory data were proportionally distributed across the two groups, with a higher frequency of values lower than or equal to 10 kU/L for all CMP fractions, with no statistical significance between the groups. Similar population studies in IgE-mediated CMPA populations are important to better characterize this phenotype and optimize diagnostic tools and treatment protocols. The role of baked therapy is also noteworthy, as it helps patients to develop tolerance to different presentations of CMP more quickly, improving their quality of life (AU)

Caries in children with lactose intolerance and cow's milk protein allergy

Abstract Dental caries in 5-to-8-year-old children with cow's milk protein allergy (CMPA) and lactose intolerance (LI), their treatment needs, and the consumption of milk-based products and milk derivatives by these patients were investigated. A cross-sectional study was undertaken with 200 children in southern Brazil in 2017. The clinical examination was based on the World Health Organization criteria and a questionnaire was sent to parents or legal guardians to collect information on the children's food intake, pre-existing systemic diseases, medication use, and CMPA and LI. Standardization was performed to verify concordance among examiners (kappa = 0.96). Caries prevalence was 67.50% in children with CMPA or LI, but 34.37% in those without these conditions. The mean dmft (decayed, missing, and filled teeth) index in children with CMPA or LI was 1.75 ± 1.84, significantly higher than among non-allergic or lactose-tolerant children (0.83 ± 1.60) (p < 0.001). In children with CMPA or LI, the mean for treatment needs was 1.58 ± 1.50. Lactose-free milk was the most frequently consumed food among allergic/intolerant children (65.00%), with a mean dmft of 2.00 ± 2.08, higher than that obtained for those without CMPA/LI (0.82 ± 0.87), showing no significant difference (p = 0.129). Although dental caries and treatment needs in primary dentition were associated with CMPA or LI, children's intake of replacement foods did not pose any risk for the development of carious lesions. Statistically significant differences were obtained for the prevalence and severity of dental caries. This shows the need for treatment of children with CMPA or LI, who had the worst caries prevalence and severity rates.

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.

Alergia a la leche y al huevo: diagnóstico, manejo e implicaciones en América Latina / Milk and egg allergy: Diagnosis, management and implications for Latin America

La sensibilización a alimentos y el desarrollo de alergias alimentarias viene aumentando en todo el mundo, siendo la leche de vaca y el huevo de gallina los principales alimentos implicados. En la mayoría de los países latinoamericanos no existen guías de manejo y cuando se elaboren deberán adaptarse a las condiciones de la población de cada región. En el presente artículo presentamos una revisión del manejo de la alergia alimentaria a la leche y al huevo útil para el personal de salud de todos los niveles, así como algunas consideraciones de los factores presentes en los países latinoamericanos.

Sensitization to food allergens, as well as the development of food allergies, is increasing worldwide, and cow´s milk and hen´s eggs are the main implicated foods. In most Latin American countries there are no management guidelines on the aforementioned topics; at their creation, such guidelines should be adapted to the conditions of the population in each region. This paper presents a review of the management of food allergy to milk and eggs useful for health personnel at all levels and some considerations of the factors found in Latin American developing countries.

Síntomas digestivos y respuesta clínica en lactantes con alergia a la proteína de leche de vaca / Gastrointestinal symptoms and clinical response of infants with cow's milk protein allergy

Introducción: La calidad de vida y estado nutricional del lactante con alergia a la proteína de leche de vaca (APLV) pueden comprometerse sin un adecuado diagnóstico y tratamiento oportuno. Objetivo: Describir síntomas digestivos, antecedentes familiares y perinatales, estado nutricional y respuesta de lactantes < 12 meses con APLV entre junio de 2007 y agosto de 2011. Pacientes y Método: Estudio retrospectivo, descriptivo en lactantes < 12 meses de edad que consultan por sospecha de APVL. Se investigaron antecedentes familiares, perinatales y características clínicas. Se excluyó a los casos sin prueba de alimentación o provocación abierta, o cuyo motivo de consulta correspondió a otra patología. Se usó el programa STATA especial edición 11,1 para el análisis estadístico. Se consideró estadístico y significativo un p < 0,05. Resultados: Se diagnosticaron 40 lactantes (57,5 por ciento varones), edad 3,0 +/- 0,4 meses, clínica de 2 +/- 0,3 meses de: vómito/regurgitación: 20, diarrea sanguinolenta: 8, falla en el crecimiento: 4, cólico/irritabilidad: 4, deposición normal con sangre en 3. Los antecedentes familiares y perinatales fueron ingesta de biberón en la 1ª semana de vida: 35, madre > 30 años: 31 casos, atopia en 2 familiares (padres/hermanos): 28, parto por cesárea: 27. Al seguimiento de 14 +/- 1,4 meses, 19 respondieron a fórmula ampliamente hidrolizada +/- seno; 19 a fórmula de aminoácidos +/- seno y un paciente lactancia exclusiva. El Z-score de P/E:-1,05 +/- 1,28; T/E: -0,96 +/- 1,60; IMC: -0,61 +/- 1,03 en primera consulta, mejoró al año: P/E: -0,15 +/- 1,24; T/E: -0,29 +/- 1,14 e IMC: -0,04 +/- 1,20 (p < 0,05), independiente de la fórmula (p = NS). Veintitres toleraron leche entera al año. Conclusiones: En este estudio los síntomas predominantes al inicio de los pacientes con APLV fueron vómitos, regurgitación y diarrea sanguinolenta. Entre los antecedentes destacan la exposición temprana a PLV, atopia familiar y parto por cesárea...

Introduction: Quality of life and nutritional status of infants with cow's milk protein allergy (CMA) can be compromised without a proper diagnosis and treatment. Objective: To describe digestive symptoms, family and perinatal history and nutritional status of < 12 month infants with CMA between June 2007 and August 2011. Patients and Method: A retrospective and descriptive study in < 12 month old infants suspecting CMA was performed. Family history, perinatal and clinical characteristics were studied. Cases without food test or open challenge test, or whose reason for consultation corresponded to other pathology were excluded. The program STATA 11.1 was used for statistical analysis and p < 0.05 was considered statistically significant. Results: 40 infants (57.5 percent boys), age 3 +/- 0.4 months and history of 2 +/- 0.3 months presenting the following: 20 of them (50 percent, vomiting/regurgitation; 8 (20 percent, bloody diarrhea; 4 (10 percent) failure to thrive; 4 (10 percent), colic/irritability and bloody normal deposition was present in 3 individuals (7.5 percent). Family and perinatal history: 35 (87.5 percent were bottle-fed during the first week of life; 31 (77.5 percent) had > 30 year old mothers; 28 (70 percent described 2 family members (parents/siblings) with atopy; 27 (67.5 percent were delivered via cesarean. At the 14 +/- 1.4-month follow-up, 19 (47.5 percent responded to extensively hydrolyzed formula +/- breastfeeding; 19 to amino acid formula +/- breastfeeding and one patient to breastfeeding exclusively. The Z -score for P/E was: -1.05 +/- 1.28; T/E: -0.96 +/- 1.60; BMI: -0.61 +/- 1.03 in the first consultation; after a year, scores improved: P/E: -0.15 +/- 1.24; T/E: -0.29 +/- 1.14 and BMI: -0.04 +/- 1.20 (p < 0.05), independent from formula (p = NS). 23 (74 percent) tolerated whole milk when reached a year old. Conclusions: In this study, the predominant early symptoms were...

Percepção dos familiares de pacientes com alergia ao leite de vaca em relação ao tratamento / Perceptions of caregivers of patients with cowÆs milk allergy regarding the treatment

Este estudo qualitativo teve como objetivo compreender as percepções de familiares de crianças e adolescentes com alergia à proteína do leite de vaca (APLV) em relação à doença e seu tratamento. Foram realizadas nove entrevistas e foi utilizado o método de análise de conteúdo. Surgiram três categorias com subcategorias: tratamento e educação do paciente e familiare(experiências vividas, base do tratamento e como lidar com a doença), resolução da doença (expectativa e melhoragradativa), qualidade de vida (inclusão social, cotidiano familiar e custo dos alimentos). Os familiares vivenciaram dificuldades durante o início do tratamento, mas revelaram que as orientações fornecidas no seguimento tornaram as adaptações à doença mais fáceis. Comentaram sobre as dificuldades em obter a colaboração de outros membros da família em relação à dieta de exclusão, suas experiências frente a uma reação alérgica, dúvidas quanto ao tratamento e lacunas do conhecimento sobre adoença entre outros médicos e na população em geral. Alguns deles acreditavam que não havia tratamento para a APLV, porque não existiam medicamentos ou vacinas, mas mantinham a esperança da descoberta de uma cura. A maioria dos familiares estava satisfeita com a melhora gradativa dos seus filhos, percebida pela redução da gravidade dos sintomas e tolerância a traços de leite. Também comentaram sobre os esforços em proporcionar uma vida normal para seus filhos, as mudanças em suas vidas e a dificuldade em comprar alimentos especiais. Em conclusão, os familiares de crianças e adolescentes com APLV sentem grande impacto da doença.

Epidemiología de la alergia alimentaria en la edad pediátria / Epidemiology of food allergy in children

La incidencia de alergia alimentaria (AA) en niños es del 2-8%. Más del 90% de las AA en los lactantes son causados por leche de vaca (LV), huevo de gallina, soya, maní, nueces, trigo, pescado y mariscos. Existen algunos factores de riesgo para el desarrollo de AA. El impacto de la LM sobre el desarrollo de las alergias es controversial. Hay un 0.21% de APLV neonatal. La introducción antes del 4 mes de vida de más de 4 alimentos está asociada con un mayor riesgo de dermatitis atópica. La prueba de provocación oral a los alimentos es una herramienta valiosa en el diagnóstico inicial y el manejo de las reacciones adversas a los alimentos. Los síntomas sugestivos de APLV pueden ser encontrados en cerca del 5-15% de los niños. La hipersensibilidad mediada por IgE a la proteína de la LV, es predominantemente una enfermedad del período del lactante.

The incidence of food allergy (FA) in children of 2-8%. Over 90% of FA in infants are caused by cow's milk (CM), chicken egg, soy, peanuts, tree nuts, wheat, fish and seafood. There are some risk factors for the development of FA. The impact of breastfeeding on the development of allergies is controversial. There is a 0.21% of neonatal CMPA. The introduction before 4 months of life of more than 4 foods is associated with an increased risk of atopic dermatitis. The oral challenge test to food is a valuable tool in the initial diagnosis and management of adverse reactions to food. Symptoms suggestive of CMPA can be found in about 5-15% of children. The IgE-mediated hypersensitivity to the protein in the CM, is predominantly a disease of the infant period.

Teste de desencadeamento alimentar oral na confirmação diagnóstica da alergia à proteína do leite de vaca / Oral food challenge test to confirm the diagnosis of cow's milk allergy

OBJETIVO: Verificar a prevalência de alergia à proteína do leite de vaca em crianças com sintomas atribuídos à ingestão do leite de vaca. MÉTODOS: Foram estudadas 65 crianças com sintomas atribuídos à ingestão do leite de vaca. A definição diagnóstica ocorreu após teste de desencadeamento alimentar oral aberto, realizado no mínimo 15 dias após dieta de exclusão e ausência de sintomas, com período de observação de até 4 semanas após o teste. Considerou-se caso (alergia à proteína do leite de vaca positiva; n = 35) criança com reaparecimento do sintoma que motivou a realização do teste, e comparação (alergia à proteína do leite de vaca negativa; n = 30) aquela sem sintomas após o período de observação do teste. RESULTADOS: A mediana de idade foi 5 meses (P 25-75 por cento 2-9 meses) no grupo caso e 7 meses (P 25-75 por cento 4-11 meses) no grupo comparação (p = 0,05). O teste não confirmou alergia à proteína do leite de vaca em 46,8 por cento dos pacientes com sintomas atribuídos à ingestão de leite de vaca. Reação tardia ocorreu em 77,1 por cento (27/35) dos casos com teste positivo, sendo 18/27 na primeira, 3/27 na segunda e 6/27 na terceira semana de observação. Encontrou-se associação estatística significante entre manifestações cutâneas e teste positivo (p = 0,04), mas não com sintomas digestivos e respiratórios. CONCLUSÃO: Os resultados corroboram a necessidade do teste de desencadeamento alimentar oral para determinar os pacientes que realmente têm alergia à proteína do leite de vaca e se beneficiarão com dieta de exclusão de leite de vaca.

OBJECTIVE: To determine the prevalence of cow's milk protein allergy in children with symptoms attributed to cow's milk intake. METHODS: Sixty-five children with symptoms attributed to cow's milk intake were studied. Diagnosis was established after an open oral food challenge test carried out at least 15 days after an elimination diet and absence of symptoms, with a follow-up period of up to 4 weeks after the test. The children who remained asymptomatic after this period were considered negative for cow's milk protein allergy (n = 30), while those whose symptoms reappeared were considered positive (n = 35). RESULTS: The median age was 5 months (P 25-75 percent 2-9 months) in the case group and 7 months (P 25-75 percent 4-11 months) in the comparison group (p = 0.05). The test did not confirm cow's milk protein allergy in 46.8 percent of the patients with symptoms attributed to cow's milk intake. A delayed reaction occurred in 77.1 percent (27/35) of the cases testing positive, 18/27 in the first week, 3/27 in the second week, and 6/27 in the third week of follow-up. A statistically significant association was found between cutaneous manifestations and positive test result (p = 0.04). However, there was no association with digestive and respiratory symptoms. CONCLUSION: Our results confirm the need of an oral food challenge test to determine which patients really have cow's milk protein allergy and may therefore benefit from a diet free of cow's milk.

Manifestaciones alérgicas en el primer año de vida / Allergic manifestations in the first year of life in a an upper middle and upper socioeconomic group of children

There is a lack of information in our country regarding allergies among infants. Objective: Measure the frequency of allergic reactions among children of an upper middle and upper socioeconomic group in Santiago, during their first year of life. Method: Chart information and telephone follow up every 3 months for a period of 12 months. Results: 7.2% of the children presented symptoms suggestive of allergies, and represented the "candidate group". At 12 months, all cases were reviewed, and 3.4% were thought to be probably allergic (48% of candidates). In all cases, the stimulus was thought to be cow's milk. Most frequent were digestive symptoms (88%), while three children had serious illness which included skin, respiratory and digestive symptoms. Treatment included maintenance of nursing when posible, and withdrawal of cow's milk from the diet, with success in all cases. Conclusion: The frequency of allergic type manifestations obtained by phone along the first year of life nearly doubled the number of diagnoses at 12 m of age. Figures obtained in the segment of population assessed were lower than those reported in other countries, mainly in Europe.

En nuestro país falta información sobre las manifestaciones de alergia en lactantes. Objetivo: Medir la frecuencia de manifestaciones alérgicas durante el primer año de vida en una cohorte de nivel socioeconómico medio y alto, nacida de Santiago. Metodología: Seguimiento de cohorte mediante llamadas telefónicas cada tres meses, durante 12 meses e información de fichas de médicos tratantes. Resultados: 7,2% reportaron síntomas potencialmente alérgicos y representaron al "grupo candidato". A los 12 meses, la evaluación caso a caso llevó a considerar que en 3,4% de la cohorte el diagnóstico más probable era alergia (48% de los candidatos); en todos los casos la proteína ofensora fue de leche de vaca. Las manifestaciones digestivas fueron las más frecuentemente informadas (88% de los casos). Tres niños tuvieron manifestaciones graves que incluían piel, aparato respiratorio y digestivo. El tratamiento mantuvo el amamantamiento cuando fue posible y retiró la leche de vaca de la dieta materna. Este tratamiento fue exitoso en todos los casos. Conclusión: La frecuencia de manifestaciones tipo alérgico a lo largo del año fue alrededor del doble de los casos considerados probablemente alérgicos a los 12 meses. Las frecuencias encontradas en el segmento de la población chilena evaluada fueron menores que la informada en otros países, especialmente europeos.

Desnutrição calórico-proteica do tipo kwashiorkor desencadeada por alergia à proteína do leite de vaca / Kwashiorkor-type malnutrition due to cow's milk protein allergy

A enteropatia induzida por proteína alimentar, uma das formas de apresentação de hipersensibilidade alimentar, tem na alergia à proteína do leite de vaca a causa mais comum dessa síndrome. Ocorre comumente em lactentes, e o diagnóstico depende de uma anamnese minuciosa associada a uma resposta clínica favorável à retirada do antígeno. No presente relato, paciente do sexo feminino de 1 ano e 8 meses, interna para investigação de desnutrição calórico-proteica grave com história de vômitos, diarreia sanguinolenta e perda ponderal pronunciada a partir dos 8 meses de idade. Amamentação exclusiva no primeiro mês de vida e fórmula láctea do segundo ao quarto mês; desde então, com leite de vaca integral. Na admissão, chorosa, irritada, emagrecida, desidratada, cabelos despigmentados e quebradiços, em anasarca e com hepatomegalia. Exames laboratoriais revelaram anemia megaloblástica, leucocitose e hipoalbuminemia. Hipóteses diagnósticas: doença celíaca, fibrose cística e alergia à proteína do leite de vaca. Realizada endoscopia digestiva alta com biópsia: discreto aumento de eosinófilos na lâmina própria em mucosa gástrica e duodenal e esofagite crônica discreta com raros eosinófilos intraepiteliais. Teste do suor negativo. Estabelecido o diagnóstico de alergia à proteína do leite de vaca desencadeando um quadro de desnutrição calórico-proteica grave do tipo kwashiorkor e iniciada dieta com hidrolisado proteico. A alergia à proteína do leite de vaca é uma apresentação clínica frequente de alergia alimentar em lactentes e pré-escolares, sendo as repercussões gastrintestinais e nutricionais significativas nessa faixa etária. Dessa forma, o diagnóstico de alergia à proteína do leite de vaca deve ser considerado em pacientes com desnutrição calórico-proteica, uma vez que a desnutrição primária, por ingestão insuficiente, tenha sido excluída.

Dietary protein-induced enteropathy is one of the presentations of food allergy, and cow's milk protein allergy (CMPA) is its most common cause, frequently affecting infants. Diagnosis depends on thorough history associated with favorable clinical response to the antigen with drawal. This case report describes the case of a twenty-month-old female patient admitted to investigate protein-energy malnutrition (PEM) with severe vomiting, bloody diarrhea and significant weight loss since eight months of age. She was breastfed during the first month of life, receiving infant formula up to the fourth month and, since then, whole cow's milk. At admission, the patient was very irritable, crying, angry, dehydrated, with severe weight loss, brittle and depigmented hair, edema and hepatomegaly. Laboratory tests showed megaloblastic anemia, leukocytosis and hypoalbuminemia. Diagnostic hypotheses: celiac disease, cystic fibrosis and CMPA. Esophagogastroduodenoscopy with biopsy showed slight increase in intra-epithelial eosinophils in the duodenum and chronic mild esophagitis with rare eosinophil infiltrate. Sweat test was negative. Diagnosis of kwashiorkor-type malnutrition triggered by CMPA was made, and hydrolyzed protein diet was started with favorable clinical outcome. CMPA is a prevalent clinical presentation of food allergy in infants and preschool children, and nutritional consequences are also important in these age groups. Therefore, CMPA diagnosis should always be considered in patients with PEM, provided the primary malnutrition secondary to insufficient food intake is excluded.

Prevalence of adverse food reactions and food allergy among Thai children.

INTRODUCTION: Adverse food reactions are not uncommon among children. Several of these reactions are IgE-mediated. Prevalence of adverse food reactions among Thai children has not been fully explored. OBJECTIVES: The objectives of the study are (1) to determine prevalence of adverse food reactions and food allergy among Thai children, (2) to determine types of foods producing such reactions, (3) to study clinical manifestations of these reactions, and (4) to study various risk factors relating to food adverse reactions among these children. MATERIAL AND METHOD: A total of 656 Thai children were surveyed (188 subjects between 6 months to 3 years of age and 468 subjects between 3 to 6 years of age). The study was a cross-sectional study. Parents answered food allergy questionnaire. Families with children reporting adverse food reactions were invited to participate in further investigation for food allergy with skin prick testings and food challenges. RESULTS: Forty-one of 656 children (6.25%) were reported to experience prior food reactions by questionnaire survey. Common foods reported to be the cause of reactions among younger children were cow's milk and eggs whereas seafood, particularly shrimp, was the most commonly reported food for older children. Three of 21 children underwent food challenge had positive challenges. Skin prick tests to incriminated food were all positive in these three children. Significant risk factors for developing adverse food reactions among these children were personal allergic history (OR = 4.89, CI 2.2-10.75) and family history of allergy (OR = 2.87, CI 1.42-5.89). CONCLUSION: Prevalence of adverse food reactions using food allergy questionnaire was 6.25%. From a limited number of those with positive food challenges, prevalence of IgE-mediated food allergy among this group of Thai children is estimated to be 0.45% (CI 0.01-0.8%).

Food Sensitization in Infants and Young Children with Atopic Dermatitis

Atopic dermatitis (AD) is a chronic, relapsing, inflammatory skin disease. Children with AD tend to have a higher prevalence of food allergies. This study investigated the clinical significance of food sensitization in AD patients. A total of 266 AD patients participated in this study. The prevalence of food sensitization and clinically relevant sensitization were compared in the subjects according to their age and AD severity. Sera from all patients were analyzed for food-specific IgE levels using the Pharmacia CAP System FEIA. The serum specific IgE levels for egg, milk, peanut and soybean were measured. Patients were regarded as sensitized to the food if their food-specific IgE levels were above 0.35 kUA/L. Also the food-specific IgE levels, the so-called diagnostic decision point, which is recommended as the clinically relevant level, for clinical food allergy, as suggested by Sampson et al, was used as an alternative method. From the measurement of food-specific IgE antibodies of the four foods, egg was the most highly sensitized and the main causative allergenic food in children with AD. The positive rates of specific IgE to the four major food allergens, and the prevalences of clinically relevant food sensitization, were higher for all foods tested in the group less than 1 year of age, and were significantly higher in moderate to severe AD compared to mild AD in infants and young children. In summary, presence of food specific IgE is prevalent in infants and young children with AD, and clinically relevant food sensitization is important in Korean infants and children with moderate to severe AD.

Prevalence of Soy Protein Hypersensitivity in Cow's Milk Protein-Sensitive Children in Korea

This study was aimed to evaluate the prevalence of soy protein hypersensitivity in cow's milk protein-sensitive children in Korea. A total of 1,363 patients with atopic dermatitis, urticaria, enterocolitis syndrome, bronchial asthma or allergic rhinitis were recruited. First, we estimated the prevalence of sensitization to soy in children sensitized to cow's milk. Specific IgE levels > 0.7 kU/L by CAP assay were considered positive. Next, the prevalence of soy allergy in cow's milk allergy (CMA) patients was investigated. Those children whose parents agreed to participate the open challenge test with soy had a convincing history of allergic reactions elicited by cow's milk and these symptoms were relieved by elimination. All of them had negative soy-specific IgE. Patients with positive soy-specific IgE accounted for 18.3% of 224 children sensitized to cow's milk protein. The prevalence of sensitization to soy decreased with age (36.8% in the first year of life, 16.4% in the second year, and 13.7% in the third year). Of 21 CMA patients, 42.9% (n=9) were determined to have soy allergy (mean age 10.3 months). Our results suggest that soy protein formula should be carefully used as a substitute for cow's milk in CMA patients, especially during infancy.

Cow milk protein allergy during the first year of life: a 12 year experience at the children's hospital, Bangkok.

CMA should be suspected for patients aged less than one year who had persistent diarrhea and/or hematemesis with no enteric pathogen found. Confirmed diagnosis could be made by Goldman challenge test. Patients with confirmed CMA should be treated by changing the cow milk feeding to soy milk feeding. However, in our study, 17% of CMA patients were also allergic to soy protein. Thus the soy milk was replaced by the elemental formula for successful treatment of this group of patients. Beside persistent diarrhea, hematemesis, anemia and hypoalbuminemia were other possible findings among patients with CMA with or without soy protein allergy.