This year I had the opportunity to give a lecture to our group that reviewed much of the important advances that happened in 2024. Here are some of the slides (if you have any trouble reading the slides, you can search for the original blog post using author name).
Recently, Dr. Victoria Martin gave our group an excellent update on cow’s milk protein allergy/food protein-induced allergic proctocolitis (FPIAP). My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.
Related blog posts:
Recently, Dr. Victoria Martin gave our group an excellent update on cow’s milk protein allergy/food protein-induced allergic proctocolitis (FPIAP). My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.
Related blog posts:
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 risk ratios:
Limitations: non-blinded study, exclusion of patients with anaphylaxis-CMA
A recent randomized clinical study (M Urashima et al. indicates that avoiding cow’s milk formula in the first 3 days of life may prevent the development of cow’s milk allergy. Thanks to Ben Gold for this reference.
Link to full Abstract (article behind paywall): Primary Prevention of Cow’s Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow’s Milk Formula at Birth
The Atopy Induced by Breastfeeding or Cow’s Milk Formula (ABC) trial, a randomized, nonblinded clinical trial, began enrollment October 1, 2013, and completed follow-up May 31, 2018, at a single university hospital in Japan. The primary outcome was sensitization to cow’s milk (IgE level, ≥0.35 allergen units [UA]/mL) at the infant’s second birthday.
Immediately after birth, newborns were randomized (1:1 ratio) to BF with or without amino acid–based elemental formula (EF) for at least the first 3 days of life (BF/EF group) or BF supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (BF plus CMF group).
If the mother, allocated to the BF/EF group, added more than 150 mL/d of EF to BF for 3 consecutive days, EF was switched to CMF after the fourth day. Thus, offspring allocated to BF/EF could avoid CMF for at least the first 3 days of life.
Key Finding:
This study is interesting in that it suggests that exposure to cow’s milk in the first three days of life potentially increases the risk of CMA, whereas a previous study (*see below) showed showed that early exposure to CMF within 14 days after birth reduces the risk of CMA. In this previous study, exposure to small quantities of CMF for the first 3 days of life was not monitored. “Thus, the results of that observational study are not necessarily in contrast to those of the present trial.”
My take: This type of study is difficult to complete. It is difficult to understand why exposure to cow’s milk in the first two weeks of life is helpful and why exposure in the first three days of life is detrimental with regard to the development of cow’s milk allergy.
*Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82.e1. doi:10.1016/j.jaci.2010.04.020)
Related blog posts:
Quebec City
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A small retrospective study suggests that eliminating cow’s milk, without other interventions, can be effective in the treatment of Eosinophilic Esophagitis (EoE) (JPGN 2012; 55: 711-16).
Out of 161 children with EoE, 17 patients were identified who excluded only cow’s milk from their diet. Remission was noted in 65%. Complete histologic remission (≤1 eosinophil/hpf) was noted in 7 patients (41%) and 4 (24%) had “significant remission” (defined as peak eosinophil count of 2-15/hpf).
This study, conducted in Chicago, took place between 2006-2011. The majority of the patients treated at this institution are treated with dietary elimination: 61% with empiric elimination diet, 8% empiric elimination diet with topical steroids, and 7% with elemental diet.
The authors suggested that younger children may be more likely to benefit from this approach but cautioned against drawing firm conclusions due to the small ‘scope’ of this retrospective study.
A recent study reports that a pH-impedance (pH-MII) may help identify children with allergen-induced gastroesophageal reflux disease (GERD) after exposure to cow’s milk (J Pediatr 2012; 161: 476-81). The study population included 17 children (average age 14 months) with a clinical diagnosis of cow’s milk allergy (CMA) who had responded to an elemental diet.
Given the limitations of the study, it is hard to take seriously the conclusions of the authors that in “selected cases of children with CMA in whom GERD is suspected” pH-MII “should be considered as part of diagnostic workup.”
The limitations:
I cannot see how obtaining a pH-MII study would offer a meaningful benefit to these patients; though, it is intriguing that one potential measure of clinical deterioration like increased weakly acid episodes can be detected when these patients are challenged with cow’s milk.
Some related blog entries:
Impedance recommendations from PIG
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