Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 3)

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In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next/past few days.

VM Martin et al. Pediatrics 2020; 146: e20200202. Open Access: Increased IgE-Mediated Food Allergy with Food-Protein-Induced Allergic Proctocolitis.

In this study of 153 infants with food protein-induced allergic proctocolitis (FPIAP) with documented blood in the stool, more children with FPIAP developed IgE-Food Allergy (IgE-FA) (11%) compared with healthy children.

Key points (from commentary by MT Kraft and D Stukus):

  • “Although conventional teaching is to wait until 12 months of age to reintroduce dairy to infants with FPIAP, it can likely be introduced much earlier.”
  • The diagnosis of FPIAP was associated with with an increased risk of IgE-FA, “although diagnosis was not confirmed through oral food challenges”

My take: Children with FPIAP are more likely to receive a diagnosis of IgE-FA. Prolonged restriction of milk, when no longer required, could contribute to this; in addition, some children are mislabeled as food allergic without appropriate confirmation (based on faulty testing).

Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 2)

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In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next few days.

R Nocerino et al. J Pediatr 2021; 232: 183-191. Open Access: The Impact of Formula Choice for the Management of Pediatric Cow’s Milk Allergy on the Occurrence of Other Allergic Manifestations: The Atopic March Cohort Study

Methods: In a 36-month prospective cohort study (n=365), the occurrence of other atopic manifestations (eczema, urticaria, asthma, and rhinoconjunctivitis) and the time of immune tolerance acquisition were comparatively evaluated in children with oral food challenge-confirmed IgE-mediated cow’s milk allergy (CWA). 5 groups were treated with extensively hydrolyzed casein formula containing the probiotic L. rhamnosus GG (EHCF + LGG), rice hydrolyzed formula, soy formula, extensively hydrolyzed whey formula (EHWF), or amino acid–based formula.

Key finding:

  • The use of EHCF + LGG for CMA treatment was associated with lower incidence of atopic manifestations and greater rate of immune tolerance acquisition.

The risk ratios:  

  • 2.37 (1.46-3.86, P < .001) for rice hydrolyzed formula vs EHCF + LGG
  • 2.62 (1.63-4.22, P < .001) for soy formula vs EHCF + LGG
  • 2.31 (1.42-3.77, P < .001) for EHWF vs EHCF + LGG
  • 3.50 (2.23-5.49, P < .001) for amino acid–based formula vs EHCF + LGG

Limitations: non-blinded study, exclusion of patients with anaphylaxis-CMA

Best Allergy Articles 2021-Cow’s Milk Allergy

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In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next few days.

T Sakihara et al. J Allergy Clin Immunol 2021; 147: 224-232.e8. Randomized trial of early infant formula introduction to prevent cow’s milk allergy

In this randomized trial, infants (n=491 enrolled) in Japan were randomly allocated to ingest at least 10 mL of CMF (cow’s milk formula) daily (ingestion group) or avoid CMF (avoidance group) between 1 and 2 months of age. In the avoidance group breast-feeding was supplemented with soy formula as needed. Oral food challenge was performed at 6 months of age to assess CMA development. Continuous breast-feeding was recommended for both groups until 6 months of age.

Key findings:

  • There were 2 CMA cases (0.8%) among the 242 members of the CMF ingestion group and 17 CMA cases (6.8%) among the 249 participants in the avoidance group (risk ratio = 0.12; 95% CI = 0.01-0.50; P < .001).
  • Approximately 70% of the participants in both groups were still being breast-fed at 6 months of age.

My take: This study adds to the growing body of evidence that early introduction of allergenic foods lowers the likelihood of developing food allergies.

Related blog posts:

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Inconclusive Screening for Cystic Fibrosis and Outcomes

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T Gonska et al. Pediatrics 2021; 148: e2021051740. Outcomes of Cystic Fibrosis Screening-Positive Infants With Inconclusive Diagnosis at School Age

Background: : Cystic fibrosis (CF) screen-positive infants with an inconclusive diagnosis (CFSPID) are infants in whom sweat testing and genetic analysis does not resolve a CF diagnosis

Methods: Prospective, longitudinal, multicenter, Canada-wide cohort study of CFSPID for a mean of 7.7 years

Key findings:

  • A CF diagnosis was established for 24 of the 115 children with CFSPID (21%) — either because of reinterpretation of the cystic fibrosis transmembrane conductance regulator genotype or because of increase in sweat chloride concentration ≥60 mmol/L. Those with initial sweat chloride concentration ≥40 mmol/L were most likely to receive a diagnosis of cystic fibrosis.
  • Children with CFSPID were pancreatic sufficient and showed normal growth until school age and had good pulmonary outcomes (similar to healthy controls)
  • In the associated commentary by P Chakraborty et al (Maximizing Benefits and Minimizing Harms: Diagnostic Uncertainty Arising From Newborn Screening), the authors note that while newborn screening (NBS) offers benefit of early diagnosis, some families can be harmed by false-positive tests or inconclusive results. Furthermore, “these issues of uncertainty are increasingly important to consider as the scope of NBS programs and their use of genomic technologies expands.”

My take: With CF, this study shows the need to monitor those with inconclusive studies. More broadly, the use of genomic testing is leading to more frequent inconclusive results in many areas and sometimes leaving more questions than answers.

Related blog posts:

From NPR, December 2021

MMWR: COVID-19 Vaccine Safety 8.7 Million Doses in 5-11 year olds

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MMWR: Open Access: COVID-19 Vaccine Safety in Children Aged 5–11 Years — United States, November 3–December 19, 2021

From Discusssion:

My take: Cardiac complications related to COVID-19 appear to be much more likely than adverse cardiac events due to vaccination.

Related blog post: Vaccination Reduces Risk of COVID-19 Associated MIS-C & New Quarantine Guidelines

Favorite Posts of 2021

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I am happy to say that this is the last nightcall that I will have this year!

Today, I’ve compiled some of my favorite posts from the past year. I started this blog a little more than 10 years ago. I am grateful for the encouragement/suggestions from many people to help make this blog better. Also, I want to wish everyone a Happy New Year.

GI:

IBD:

LIVER:

Nutrition:

Other Topics:

Thanks to Jennifer

Timing of Solids and Weight Trajectory

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CJ D’Hollander et al. J Pediatr 2022; 240: 102-109. Timing of Introduction to Solid Food, Growth, and Nutrition Risk in Later Childhood

Methods: A longitudinal cohort study was conducted among healthy children 0-10 years of age participating in The Applied Research Group for Kids study between June 2008 and August 2019 in Toronto, Canada.

Key findings:

  • Of 8943 children included, the mean (SD) age of infant cereal introduction was 5.7 (2.1) months
  • Children who were introduced to infant cereal at 4 vs 6 months had 0.17 greater body mass index z score (95% CI 0.06-0.28; P = .002) and greater odds of obesity (OR 1.82; 95% CI 1.18-2.80; P = .006) at 10 years of age. 
  • Earlier cereal introduction was associated with a less-favorable eating behavior score at 18 months to 5 years of age (0.18 units higher; 95% CI 0.07-0.29; P = .001).

Limitation: This study did not randomize children into early vs late cereal introduction; thus, there may be unidentified confounders that contribute to weight gain in children offered cereal at a younger age.

My take: This study indicates that introduction of cereal at 6 months of age, rather than 4 months of age, may be beneficial in limiting excess weight gain.

Vaccination Reduces Risk of COVID-19 Associated MIS-C & New Quarantine Guidelines

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M Levy et al. JAMA. Published online December 20, 2021. doi:10.1001/jama.2021.23262. Open Access: Multisystem Inflammatory Syndrome in Children by COVID-19 Vaccination Status of Adolescents in France

Key findings:

  • From September 1, 2021, to October 31, 2021, a total of 107 children with MIS-C were hospitalized in France…33 (31%) were adolescents eligible for vaccination
  • Among those with MIS-C, 0 had been fully vaccinated, 7 had received 1 dose with a median (IQR) time between vaccine injection and MIS-C onset of 25 (17-37) days, and 26 had not been vaccinated. The HR for MIS-C was 0.09 (95% CI, 0.04-0.21; P < .001) after the first vaccine dose compared with unvaccinated adolescent. Because there were no MIS-C cases in those who were vaccinated, an HR cannot be calculated in this group.
  • The study had limitations, including the low number of patients, use of national data to calculate HR without considering regional variations, and inability to control for individual risks of MIS-C, such as sex, race and ethnicity, and comorbidities

My take: This study indicates that COCID-19 vaccination likely results in a marked decrease in the risk of MISC-C. This finding provides an additional reason favoring vaccination in adolescents in terms of risk-benefit calculation for immunization.

12/27/21: CDC Updates and Shortens Recommended Isolation and Quarantine Period for General Population

Superior Results for Over-The Scope Clip for Severe UGI Bleeding

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DM Jensen et al. Clin Gastroenterol Hepatol 2021; 19: 2315-2323. Randomized Controlled Trial of Over-the-Scope Clip as Initial Treatment of Severe Nonvariceal Upper Gastrointestinal Bleeding

Editorial: NS Buttar et al. Clin Gastroenterol Hepatol 2021; 19: 2266-2269. Full Text -Open Access: Silencing the Erupter: Over-the-Scope Clip in the Management of Nonvariceal Upper Gastrointestinal Bleeding

Background: “The OTSC (Ovesco Endoscopy AG, Tubingen, Germany) is a flexible, biocompatible nitinol clip that has multiple teeth oriented like a bear-claw, deployed via a band ligation–type mechanism. It is substantially larger than standard 2-tined hemostatic clips, allowing 1 OTSC to entrap far more tissue in a full-thickness bite. This unique design and its marked compressive force are purportedly capable of clinching even large vessels in excavated/fibrotic/near-perforating ulcers that are in complex anatomic locations. The bear-claw design allows not only for better tissue capture, but also adds higher site stability.”

53 patients (from cohort of 346) met the following criteria:

  • (1) clinical instability (hypotension, shock, syncope, tachycardia, melena, hematemesis, and/or hematochezia)
  • (2) laboratory evidence of high-volume blood loss (hemoglobin level ≤9 g/dL, or hemoglobin level decrease of ≥2 g/dL from baseline at admission)
  • (3) need for packed red blood cell (PRBC) transfusion (received 1 or more units PRBC)

In this study, the authors compared OTSC to standard treatment (hemoclips or multipolar electrocoagulation).

Key findings from study:

  • Immediate hemostasis was achieved in all patients.
  • The cumulative 30-day rebleeding rate was significantly lower in the OTSC group than in the standard group (4% vs 28.6%; P = .017), with most patients experiencing rebleeding within 4 days. All rebleeds occurred in patients with major stigmata of recent hemorrhage (SRH) and none with lesser SRH. SRH included active spurting bleeding, visible vessel, or clot.
  • The number of PRBC units transfused was also significantly higher in the standard versus OTSC group (0.68 vs 0.04 units; P = .03).
  • Severe complications were less frequent in OTSC (0 % vs. 14.3%)
  • Limitations:  despite randomization, within the groups, major SRH with active arterial bleeding (Forrest 1A) was observed in a higher number of patients in the standard group (7 standard vs 2 OTSC) and study was conducted in specialized quaternary medical center with high expertise. In addition, “whether it should be used in all cases of NVUGIB or be reserved for patients with a high-risk for adverse outcome lesions12 remains to be addressed.”
  • The editorial reviewed two other studies supporting the superiority of OTSC: FLETRock and STING.

My take (from editorial): The data about improved outcomes in the OTSC compared with standard therapy are compelling. Training in OTSC application will be needed for more widespread adoption.

Related blog posts:

From The Onion