Growth of infants with gastrointestinal manifestations of cow's milk protein allergy / Crescimento de lactentes com manifestações gastrointestinais de alergia à proteína do leite de vaca

ABSTRACT Objective To assess linear growth and weight gain in infants with suspected cow's milk protein allergy with gastrointestinal manifestations, seen at a gastropediatrics clinic. Methods A retrospective cohort study conducted with demographic, clinical, anthropometric and dietary information on 84 infants first seen between 2015 and 2018 and followed-up for six months. Stature-for-age, weight-for-age, and body mass index-for-age in z-scores were evaluated according to the cut off points established by the World Health Organization in 2006. Accelerated growth or catch-up was considered a gain ?0.67 in the z-score of the referred indices, evaluated at 3 and 6 months. Results Median age at baseline was 4.0 months and 88.1% of the infants were already in diet exclusion. Regarding the anthropometric evaluation short stature frequency was 15.5% and the underweight frequency was 8.3% and 3.6% respectively based on the weight-for-age and body mass index-for-age indices. High recovery growth was observed during the follow-up period but was not considered catch up. In boys, the gains in weight-for-age and body mass index-for-age were significant (p=0.02 and p=0.01 respectively) and close to the threshold that characterizes the catch up, 0.58 and 0.59, respectively. In girls, significant gains in stature-for-age and weight-for-age (0.38 and 0.37 respectively, p=0.02 for both) were observed. Conclusion Infants with suspected cow's milk protein allergy with gastrointestinal manifestations should have early access to specialized nutritional counseling to avoid exposure to allergenic food and control allergy symptoms, thereby avoiding malnutrition and ensuring adequate nutritional recovery.

RESUMO Objetivo Avaliar o crescimento linear e o ganho de peso de lactentes com suspeita de alergia à proteína do leite de vaca, com manifestações gastrointestinais, atendidos em um ambulatório de gastropediatria. Métodos Estudo de coorte retrospectivo, com informações demográficas, clínicas, antropométricas e dietéticas de 84 lactentes que iniciaram atendimento entre 2015 e 2018 e foram acompanhados durante seis meses. Foram avaliados os índices estatura/idade, peso/idade e índice de massa corporal/idade em escore-z, segundo os pontos de corte da Organização Mundial de Saúde de 2006. Considerou-se crescimento acelerado (ou catch-up growth) um ganho ?0,67 escore-z nos referidos índices, avaliados em três e seis meses. Resultados No baseline, a mediana de idade foi 4,0 meses e 88,1% dos lactentes já estavam em dieta de exclusão. A frequência de baixa estatura foi de 15,5% e a de baixo peso foi de 8,3% e de 3,6% segundo os índices peso/idade e índice de massa corporal/idade, respectivamente. Houve elevado crescimento de recuperação durante o período de acompanhamento, mas que não configurou catch up. Nos meninos, ganhos no peso/idade e índice de massa corporal/idade foram significantes (p=0,02 e p=0,01) e próximos do limiar que caracteriza catch up: 0,58 e 0,59, respectivamente. Nas meninas, foram observados ganhos significantes na estatura/idade e peso/idade, de 0,38 e 0,37 (p=0,02 para ambos). Conclusão Demonstrou-se que lactentes com suspeita de alergia à proteína do leite de vaca, com manifestações gastrointestinais, deveriam ter acesso precoce ao aconselhamento nutricional para evitar exposição ao alimento alergênico, controlar sintomas e, assim, evitar a desnutrição ou garantir recuperação nutricional adequada.

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.

Parte: manejo de la alergia a la proteína de leche de vaca / Part 2: Cow ́s Milk Protein Allergy Management

La lactancia materna es un excelente factor protector y una forma inigualable de facilitar el alimento ideal para el crecimiento y desarrollo saludable. Es imprescindible su recomenda-ción exclusiva durante los primeros 6 meses de vida y de ser posible continuar con la lactancia materna durante la alimentación complemen-taria hasta los 2 años de edad; solo se debe recurrir a fórmulas especiales cuando la madre no pueda amamantar. Para estos casos se dispone de varias fórmulas hidrolizadas, soja y elementales.Las fórmulas hidrolizadas pueden ser extensa o parcialmente hidrolizadas, y ser séricas o de caseína. Las fórmulas extensamente hidroliza-das, han sido sometidas a ensayos clínicos donde se comprueba su hipoalergenicidad al eliminar los síntomas de la Alergia a la Proteína de la Leche de Vaca (APLV) luego de su inicio. Estudios recientes demuestran que la adición de Lactobacillusr hamnosus (LGG) a una fórmu-la de caseína extensamente hidrolizada acelera la adquisición de tolerancia en estos niños en comparación con los pacientes que recibieron fórmula sin adición.La fórmula de soja, aunque no es hipoalergéni-ca, se puede emplear para tratar la APLV, pero no antes de los 6 meses. No se pueden emplear como tratamiento de APLV fórmulas parcial-mente hidrolizadas, ni leche de otros rumian-tes, como oveja o cabra. En pacientes con altos niveles de sensibilización o con antecedente de reacción ana láctica, se recomienda la administración de fórmula elemental. El objeti-vo de la presente revisión es dar a conocer el manejo y uso racional de las fórmulas hidroliza-das y elementales en niños con APLV y así evitar el uso indiscriminado de estas en niños con trastornos funcionales...(AU)

Signs and symptoms associated with digestive tract development / Sinais e sintomas associados com o desenvolvimento do trato digestivo

ABSTRACT Objective: To analyze the development and prevalence of gastrointestinal signs and symptoms associated with the development of the digestive tract, and to assess the measures aimed to reduce their negative impacts. Source of data: Considering the scope and comprehensiveness of the subject, a systematic review of the literature was not carried out. The Medline database was used to identify references that would allow the analysis of the study topics. Synthesis of results: Infants frequently show several gastrointestinal signs and symptoms. These clinical manifestations can be part of gastrointestinal functional disorders such as infantile colic, infant regurgitation, and functional constipation. Allergy to cow's milk protein and gastroesophageal reflux disease are also causes of these clinical manifestations and represent an important and difficult differential diagnosis. The diseases that course with gastrointestinal signs and symptoms can have an impact on family dynamics and maternal emotional status, and may be associated with future problems in the child's life. Comprehensive pediatric care is essential for diagnosis and treatment. Maternal breastfeeding should always be maintained. Some special formulas can contribute to the control of clinical manifestations depending on the established diagnosis. Conclusion: During the normal development of the digestive tract, several gastrointestinal signs and symptoms may occur, usually resulting from functional gastrointestinal disorders, gastroesophageal reflux disease, and allergy to cow's milk protein. Breastfeeding should always be maintained.

RESUMO Objetivo: Analisar o desenvolvimento e a prevalência de sinais e sintomas gastrintestinais associados com o desenvolvimento do tubo digestivo e as medidas que visam a diminuir suas repercussões negativas. Fontes dos dados: Considerando a abrangência e amplitude do tema, não foi feita revisão sistemática da literatura. Usou-se a base de dados do Medline para a identificação de referências bibliográficas que permitissem contemplar os temas de estudo. Síntese dos resultados: O lactente apresenta com elevada frequência sinais e sintomas gastrintestinais. Essas manifestações clínicas podem fazer parte de distúrbios funcionais gastrintestinais, como cólica, regurgitação e constipação intestinal funcional. A alergia à proteína do leite de vaca e a doença do refluxo gastroesofágico também são causas dessas manifestações clínicas e representam um importante e difícil diagnóstico diferencial. As doenças que cursam com sintomas e sinais gastrintestinais podem ter consequências na dinâmica familiar e no estado emocional das mães. Podem se associar com problemas na vida futura da criança. A atenção pediátrica completa é fundamental para o diagnóstico e o tratamento. O aleitamento natural deve sempre ser mantido. Algumas fórmulas especiais podem contribuir para o controle das manifestações clínicas na dependência do diagnóstico estabelecido. Conclusão: Durante o desenvolvimento normal do tubo digestivo podem ocorrer sinais e sintomas gastrintestinais em geral decorrentes dos distúrbios gastrintestinais funcionais, da doença do refluxo gastroesofágico e da alergia à proteína do leite de vaca. Aleitamento natural deve sempre ser mantido.

Características clínicas asociadas a colitis eosinofílica en lactantes con rectorragia persistente / Clinical features of Eosinophilic Colitis in infants with persistent rectal bleeding

The most common presentation of cow's milk protein allergy (CMP) in infants is known as eosinophilic colitis (EC). The aim of this study is to evaluate EC characteristics in infants evaluated with colonoscopy due to the presence of rectorrhagia. Patients and Methods: A retrospective case-control study. Left-sided colonoscopy records of infants with persistent rectal bleeding, conducted between January 2006 and March 2011, were reviewed. The cases corresponded to infants with rectal biopsy compatible with EC and controls with negative biopsy. Telephone questionnaires to parents were conducted, evaluating personal and family history. Results: Complete records were obtained in 61 (79%) of the 77 procedures. 33 (54%) of them were males. Examination average age was 6.3 ± 5.9 months. 25 (41%) patients had EC on their histology. Between cases and controls, no significant difference in gestational age, birth weight and gender, only regarding age at the time of rectal bleeding, were observed. There was also no difference in personal history regarding obstructive bronchitis, allergic rhinitis, family history of asthma, allergic rhinitis or other food allergies. Those who received artificial feeding did not presented greater risk of EC. The most common symptoms in the cases did not differ significantly from the controls. Conclusions: The prevalence of EC in the children studied was 40.9%. Our results show that there are groups of patients with persistent rectal bleeding in which there is no personal or family history that helps diagnosing EC. An endoscopic study could be considered in these patients to establish a correct diagnosis of this condition, avoid unnecessary diets and not to delay the detection of other diseases.

En lactantes, la forma de presentación más común de la alergia a la proteína de la leche de vaca (PLV) es la colitis eosinofílica (CE). El objetivo de este trabajo es evaluar características clínicas asociadas a CE en lactantes evaluados con colonoscopía por la presencia de rectorragia. Pacientes y Método: Estudio caso-control, retrospectivo. Se revisaron registros de colonoscopía izquierda de lactantes con rectorragia persistente, realizadas entre Enero 2006 y Marzo 2011. Casos fueron lactantes con rectorragia y biopsia compatible con CE y controles aquellos con biopsia negativa. Se realizó un cuestionario vía telefónica a los padres, evaluándose antecedentes personales y familiares. Resultados: En 61 (79%) de 77 procedimientos se obtuvo registros completos. 33 (54%) eran hombres. Edad promedio del examen fue 6,3 ± 5,9 meses. 25 (41%) pacientes presentaron CE en la histología. Sin diferencia significativa en edad gestacional, peso de nacimiento ni sexo, pero si en edad de presentación de la rectorragia, entre casos y controles. Tampoco hubo diferencia en antecedentes personales de bronquitis obstructivas, rinitis alérgica, ni antecedentes familiares de asma, rinitis alérgica u otras alergias alimentarias. Quienes recibieron lactancia artificial no tuvieron mayor riesgo de CE. Los síntomas más frecuentes en los casos no se diferenciaron significativamente de los controles. Conclusión: La prevalencia de CE en los niños estudiados fue de 40,9%. Nuestros resultados muestran que hay grupos de pacientes con rectorragia persistente en los cuales no existen antecedentes de la historia familiar ni personal que permitan establecer el diagnóstico de CE. Es en estos pacientes en los cuales podría considerarse el estudio endoscópico para establecer un correcto diagnóstico de esta patología, evitar dietas innecesarias y no retrasar la detección de otras enfermedades.

Gastroesophageal reflux disease: exaggerations, evidence and clinical practice / Doença do refluxo gastroesofágico: exageros, evidências e a prática clínica

OBJECTIVE: there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. DATA SOURCE: a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. DATA SYNTHESIS: abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. CONCLUSIONS: there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected. .

OBJETIVO: há muitas dúvidas e poucas evidências para o diagnóstico e tratamento da doença do refluxo gastroesofágico (DRGE) na criança. A relação entre a DRGE e a alergia às proteínas do leite de vaca (APLV), o uso exagerado da ultrassonografia abdominal para diagnóstico da DRGE e o excesso de medicamentos, especialmente dos inibidores de bomba de prótons (IBP), são alguns aspectos que necessitam esclarecimentos. Esta revisão tem como objetivo estabelecer as evidências científicas atuais para o diagnóstico e tratamento da DRGE em pediatria. FONTES DOS DADOS: foram pesquisadas nas bases de dados eletrônicos do Medline, Pubmed, Lilacs, Cochrane Library e Scielo, nas diferentes faixas etárias da pediatria, até maio de 2013, as seguintes palavras-chave: refluxo gastroesofágico, doença do refluxo gastroesofágico, inibidores da bomba de prótons e procinéticos. SíNTESE DOS DADOS: a ultrassonografia de abdome não deve ser recomendada para pesquisa de refluxo gastroesofágico (RGE). O tratamento simultâneo da DRGE e da APLV induz, muitas vezes, ao uso desnecessário de medicação ou dieta de exclusão. Não existem evidências suficientes para prescrição de procinéticos em todos os portadores de RGE/DRGE. Poucas evidências fornecem suporte para a supressão ácida, no primeiro ano de vida, para tratamento de sintomas inespecíficos, sugestivos de DRGE. O tratamento conservador traz muitos benefícios e poucos gastos, sem efeitos colaterais. CONCLUSÕES: existem poucos estudos controlados e randomizados que avaliam a DRGE na criança e nenhum exame pode considerado padrão-ouro para o seu diagnóstico. Por esses motivos, ocorrem exageros no diagnóstico e no tratamento dessa doença, e que necessitam ...

Eosinophilic colitis in infants / Colite eosinofílica em lactentes

OBJECTIVE: To review the literature for clinical data on infants with allergic or eosinophilic colitis. DATA SOURCE: MEDLINE search of all indexes was performed using the words ''colitis or procto-colitis and eosinophilic'' or ''colitis or proctocolitis and allergic'' between 1966 and February of 2013. All articles that described patients' characteristics were selected. DATA SYNTHESIS: A total of 770 articles were identified, of which 32 met the inclusion criteria. The 32 articles included a total of 314 infants. According to the available information, 61.6% of infants were male and 78.6% were younger than 6 months. Of the 314 patients, 49.0% were fed exclusively breast milk, 44.2% received cow's milk protein, and 6.8% received soy protein. Diarrheal stools were described in 28.3% of patients. Eosinophilia was found in 43.8% (115/263) of infants. Colonic or rectal biopsy showed infiltration by eosinophils (between 5 and 25 perhigh-power field) in 89.3% (236/264) of patients. Most patients showed improvement with theremoval of the protein in cow's milk from their diet or the mother's diet. Allergy challenge tests with cow's milk protein were cited by 12 of the 32 articles (66 patients). CONCLUSIONS: Eosinophilic colitis occurs predominantly in the first six months of life and in males. Allergy to cow's milk was considered the main cause of eosinophilic colitis. Exclusion of cow'smilk from the diet of the lactating mother or from the infant's diet is generally an effective therapeutic measure. .

OBJETIVO: Revisão da literatura sobre dados clínicos de lactentes com colite eosinofílica oualérgica. FONTE DOS DADOS: Pesquisa no Medline de todas as indexações com as palavras ''colitis or proc-tocolitis and eosinophilic'' ou ''colitis or proctocolitis and allergic'' entre 1966 e fevereiro de 2013. Foram selecionados todos os artigos que descreviam as características dos pacientes. SÍNTESE DOS DADOS: Foram identificados 770 artigos dos quais 32 preenchiam os critérios de inclusão. Os 32 artigos incluíram o total de 314 lactentes. Conforme as informações disponíveis, 61,6% dos lactentes eram do sexo masculino e 78,6% apresentavam idade inferior a 6 meses. Dos 314 pacientes, 49,0% encontrava-se em aleitamento natural exclusivo, 44,2% recebiam proteína do leite de vaca e 6,8% proteína da soja. Fezes diarreicas foram descritas em 28,3% dos pacientes. Eosinofilia foi encontrada em 43,8% (115/263) dos lactentes. Biópsia retal ou colônica mostrou infiltração por eosinófilos (entre 5 e 25 por campo de grande aumento) em 89,3% (236/264) dos pacientes. A maioria dos pacientes apresentou melhora com a retirada da proteína do leite de vaca da sua dieta ou das suas mães. Teste de desencadeamento com proteína do leite de vaca foi citado em 12 dos 32 artigos (66 pacientes). CONCLUSÕES: Colite eosinofílica ocorre predominantemente nos primeiros seis meses de vida e no sexo masculino. Alergia ao leite de vaca foi considerada a principal causa de colite eosinofílica. Dieta de exclusão do leite de vaca da mãe lactante ou da dieta do lactente é uma medidate rapêutica geralmente eficaz. .

[Effect of cow's milk elimination from children diet on chronic constipation]

Children constipation is one of the common causes of abdominal pain. Cow's milk in children diet is suggested to be one of the main cause of chronic constipation. This study was performed to determine the effect of cow's milk elimination from children diet with chronic constipation. This quasi-experimental study, was performed on 80 children with chronic constipation. Rome-III criteria were considered for disease diagnosis. Cow's milk was eliminated for three weeks from children's diet and the clinical symptoms in children were surveyed, subsequently. Constipation was cured in 33.8% of children as result of cow's milk free diet. The rate of treatment response in affecting children whom their disease in began under 2 years of age [52.6%] was significantly higher than others [16.6%] [P<0.05]. Children treatment was not significantly related to child's gender and amount of milk consumption. Eliminating of cow's milk from the diet improves the chronic constipation in children

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.

Retrospective Analysis of the Natural History of Atopic Dermatitis Occurring in the First Year of Life in Korean Children

The aim of this study was to analyze the natural history of atopic dermatitis (AD) and the risk factors associated with the remission of AD in Korean children. We enrolled 597 children with AD that occurred in the first year of life. A variety of factors influencing the prognosis were assessed by medical records and telephone interviews. Their outcome was classified into complete remission, intermittent, and persistent AD. AD had completely disappeared in 422 cases (70.6%), while 149 (25%) and 26 cases (4.4%) showed intermittent and persistent skin symptoms, respectively. The average healing time was 29.6 months in complete remission group and expected healing time of the AD was 60 months. None of risk factors were significant by multivariate analysis. But, in moderate-to-severe AD group, maternal diet restriction during lactation (P = 0.046) and no sensitization to cow's milk (P = 0.017) were significantly associated with remission of AD in the multivariate analysis. In conclusion, AD occurring in the first year of life disappears in a significant proportion of patients. In addition, in Korean children with moderate-to-severe AD, maternal diet restriction of allergenic food during lactation and sensitization to cow's milk seem to predict the prognosis of AD.

Natural Course of Cow's Milk Allergy in Children with Atopic Dermatitis

Cow's milk is one of the most common food allergens in children with atopic dermatitis (AD). This study was conducted to describe the natural course of cow's milk allergy in children with AD, and to identify factors predictive of outcome. To accomplish this, we reviewed the medical records of 115 children who were diagnosed with AD and cow's milk allergy before 24 months of age to evaluate their clinical characteristics and prognostic factors. During a follow-up period of 24 to114 months, the median age for tolerance to cow's milk was found to be 67 months. Multivariate analysis using the Cox proportional hazard model revealed that the peak cow's milk-specific IgE level within 24 months after birth was the most important factor for prediction of the outcome of cow's milk allergy. In conclusion, half of the children younger than 24 months of age with AD and cow's milk allergy could tolerate cow's milk at 67 months of age. The peak cow's milk-specific IgE level within the first 24 months of birth is useful to predict the prognosis of cow's milk allergy in children with AD.

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.

Alergia a la proteína de la leche de vaca: propuesta de Guía para el manejo de los niños con alergia a la proteína de la leche de vaca / Cow’s milk protein allergy: proposed guidelines for the management of children with cow’s milk protein allergy

El diagnóstico y manejo de la alergia a la proteína de leche de vaca es un verdadero desafío en la práctica pediátrica. Como se trata de una patología que pareciera estar aumentando en nuestro medio, de un modo similar a lo comunicado en otras latitudes, hemos considerado conveniente proponer una normalización de la nomenclatura y de la metodología diagnóstica. Un grupo de pediatras especialistas se ha reunido para realizar una Propuesta de Guía para el manejo de los niños con alergia a la proteína de la leche de vaca. El objetivo ha sido difundir el conocimiento actual de la fisiopatología, factores ambientales y sus manifestaciones clínicas, para colaborar con el pediatra mediante algoritmos que faciliten su manejo integral.

Cow’s milk allergy is a growing concern in the practice of pediatrics. The impression of an increasing incidence, similar to what has been reported in other latitudes, has determined the need for guidelines to help in the diagnosis and treatment of this disease. A group of pediatric specialists met to discuss the “state of the art” and propose local guidelines to deal with cow’s milk allergy. The aim has been to contribute in the understanding of the pathophysiology, environmental factors, and clinical expressions of this problem, and help pediatricians in the overall management.

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.

Skin sensitization to common allergens in Turkish wheezy children less than 3 years of age.

Infants and small children with asthma are not commonly skin tested, as allergy is not considered to be a major cause of infantile asthma. The aim of this study was to determine the frequency of skin test positivity to various allergens in wheezy children less than 3 years of age. We evaluated 161 patients with infantile asthma (median age 20 months) and 100 healthy controls (median age 18 months). Infantile asthma was defined as three or more episodes of wheezing in a child less than 3 years of age, whose symptoms improved on treatment with beta-agonist and anti-inflammatory agents. All children were skin tested to house dust mites (HDM), pollens, molds, and cow milk extracts using prick technique. One hundred and eighteen (73.3%) children In the patient group tested positive to HDM, 84 (52.1%) to pollens, 37 (22.9%) to molds, and 16 (10%) to cow milk. Sensitization rates to HDM were significantly higher in the patient group than In the healthy controls. Sensitization rates to pollens were not statistically different between the two groups. There was no association between family history of atopy and frequency of sensitization to allergens in the wheezy and control groups. We concluded that skin sensitization to allergens was common In wheezy infants. The prevalence of sensitization to indoor allergens was higher than to outdoor or food allergens.

Hematemesis in infants induced by cow milk allergy.

This study was conducted in order to analyze the clinical manifestations, the endoscopic findings, the histology of the gastrointestinal mucosa, the treatments and the clinical course in infants who had hematemesis induced by cow milk allergy. The medical records were reviewed retrospectively. The criteria for the diagnosis of CMA included elimination of cow milk formula resulting in improvement of symptoms, specific endoscopic and histologic findings as well as the exclusion of other causes. Twenty-three infants with a diagnosis of hematemesis were analyzed, which included 20 infants with CMA and 3 infants with gastroesophageal reflux disease (GERD). In the CMA group were 12 girls and 8 boys whose ages were 4.3 +/- 1.4 months. The onset of vomiting after starting cow milk formulas was 70.6 +/- 48.9 days. Gastroduodenoscopy was performed on 15 patients showing erythema, erosion and friability of the gastric mucosa in all patients and lymphoid hyperplasia in the duodenal bulb in 7 patients. Eight patients had mild to moderate eosinophilic infiltration and 5 patients had eosinophilia. Cow milk formulas were changed to other formulas: two children were initially given extensively hydrolyzed casein formulas and later followed by a soy formula, 14 were given a soy formula and 4 were given partially whey hydrolyzed formulas. All patients showed clinical signs of improvement a few days later. Patients that were able to tolerate cow milk were 1.5 +/- 0.9 years old. During the follow-up period (2.6 +/- 1.8 years after treatment) 4 patients were diagnosed with asthma, 4 patients with chronic respiratory symptoms, 4 patients with constipation and 2 others with food allergies. CMA induced gastritis in infancy may not be classified as eosinophilic gastritis because of the low level of eosinophilic infiltration. The elimination of cow milk and subsequent substitution with a soy formula is the proper management.