SYNOPSIS Cow’s milk allergy (CMA) affects 2% to 3% of young children and presents with a wide range of immunoglobulin E (IgE-) and non-IgE-mediated clinical syndromes, which have a significant economic and lifestyle impact. Definitive diagnosis is based on a supervised oral food challenge (OFC), but convincing clinical history, skin prick testing, and measurement of cow’s milk (CM)-specific IgE can aid in the diagnosis of IgE-mediated CMA and occasionally eliminate the need for OFCs. It is logical that a review of CMA would be linked to a review of soy allergy, as soy formula is often an alternative source of nutrition for infants who do not tolerate cow’s milk. The close resemblance between the proteins from soy and other related plants like peanut, and the resulting cross-reactivity and lack of predictive values for clinical reactivity, often make the diagnosis of soy allergy far more challenging. This review examines the epidemiology, pathogenesis, clinical features, natural history and diagnosis of cow’s milk and soy allergy. Cross-reactivity and management of milk allergy are also discussed.

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BackgroundProbiotic administration has been proposed for the prevention and treatment of specific allergic manifestations such as eczema, rhinitis, gastrointestinal allergy, food allergy, and asthma. However, published statements and scientific opinions disagree about the clinical usefulness.ObjectiveA World Allergy Organization Special Committee on Food Allergy and Nutrition review of the evidence regarding the use of probiotics for the prevention and treatment of allergy.MethodsA qualitative and narrative review of the literature on probiotic treatment of allergic disease was carried out to address the diversity and variable quality of relevant studies. This variability precluded systematization, and an expert panel group discussion method was used to evaluate the literature. In the absence of systematic reviews of treatment, meta-analyses of prevention studies were used to provide data in support of probiotic applications.ResultsDespite the plethora of literature, probiotic research is still in its infancy. There is a need for basic microbiology research on the resident human microbiota. Mechanistic studies from biology, immunology, and genetics are needed before we can claim to harness the potential of immune modulatory effects of microbiota. Meanwhile, clinicians must take a step back and try to link disease state with alterations of the microbiota through well-controlled long-term studies to identify clinical indications.ConclusionsProbiotics do not have an established role in the prevention or treatment of allergy. No single probiotic supplement or class of supplements has been demonstrated to efficiently influence the course of any allergic manifestation or long-term disease or to be sufficient to do so. Further epidemiologic, immunologic, microbiologic, genetic, and clinical studies are necessary to determine whether probiotic supplements will be useful in preventing allergy. Until then, supplementation with probiotics remains empirical in allergy medicine. In the future, basic research should focus on homoeostatic studies, and clinical research should focus on preventive medicine applications, not only in allergy. Collaborations between allergo-immunologists and microbiologists in basic research and a multidisciplinary approach in clinical research are likely to be the most fruitful.

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These results indicate that AAs critical for IgE binding are more heterogeneous than initially defined by pooled milk-allergic patient sera. For future immunotherapeutic interventions with mutated peptides, critical AAs should also be identified with individual patient sera to account for heterogeneity of IgE binding between patients.

REsumoObjetivo: Revisar os principais protocolos de padronização para o teste de provocação oral aberto aplicado a crianças com suspeita de alergia ao leite de vaca mediada por imunoglobulina E.Fontes de dados: Foram selecionados artigos publicados, nos últimos dez anos, nas bases de dados Medline, Lilacs e SciELO, utilizando-se os descritores de assunto: "hipersensibilidade alimentar", "leite de vaca", "alergia ao leite de vaca", "teste de provocação oral", "crianças" e "diagnóstico".Síntese dos dados: O teste de provocação oral é o méto-do mais fidedigno para estabelecer ou excluir o diagnóstico de alergia alimentar e sua forma aberta pode ser a primeira opção, quando apenas reações objetivas são esperadas. O local para realizar o teste deve possuir todos os recursos para tratamento de emergência. Como preparo, o paciente deve seguir dieta de exclusão do alimento suspeito e descontinuar o uso de medicamentos que possam interferir no resultado do teste. Habitualmente, utilizam-se 8 a 10g de leite em pó ou 100mL de leite fluido, oferecidos em volumes progressivos, a intervalos de dez a 60 minutos. Apesar da rigidez do método, ainda existem situações em que há dificuldade de interpretação dos resultados; por isso, médicos bem treinados devem aplicar o teste, sendo cautelosos ao julgarem as reações.Conclusões: Mesmo considerando as limitações que dificultam a aplicação do teste de provocação oral na prática clínica, a implementação do teste nos serviços de saúde poderia reduzir diagnósticos falsos-positivos de alergias.Palavras-chave: hipersensibilidade alimentar; substitutos do leite humano; diagnóstico. AbsTRAcTObjective: To review the main standardization protocols of the open oral food challenge applied to children with suspicion of cow's milk allergy mediated by immunoglobulin E.Data source: Medline, Lilacs and SciELO databases were searched for articles published in the last ten years using the following descriptors: "food hypersensitivity", "cow's milk", "cow's milk allergy", "oral food challenge", "children" and "diagnosis".Data synthesis: The oral food challenge test is the most reliable method to establish or exclude the diagnosis of food allergy and the open challenge can be the first option when only objective reactions are expected. All medications and equipment needed for emergency treatment should be available. Before being submitted to the test, the patient must follow a diet excluding the suspected food and discontinue the use of medications that may interfere with the results of the test. Usually, it is performed using 8-10g of powdered milk or 100mL of fluid milk, offered in progressive volumes