Factors Associated with the Development of Immune Tolerance in Children with Cow’s Milk Allergy

Sánchez-Valverde, F.; Etayo, Veronica; Gil, Francisco Javier Martín; Aznal, Elena; Martínez, Diego; Amezqueta, Ana; Mendizabal, Mikel; Galbete, Arkaitz; Pastor, Nítida; Vanderhoof, Jon A.

doi:10.1159/000499319

Cited by 18 publications

(16 citation statements)

References 29 publications

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“…These foods are rarely explored in the IYCF literature with most available studies reporting on associations with health outcomes, such as allergy risk or child growth. 22,23 These results add further evidence that follow-on and toddler milks are now prominent in the diets of children worldwide, and especially in children living in middle income countries. 5,24 Guidance from WHO deems follow-up and toddler formula unnecessary and unsuitable as BMS, and recognizes these products have partially or totally replaced the consumption of breastmilk.…”

Section: Discussionsupporting

confidence: 52%

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Consumption of breast milk, formula and other non-human milk by children aged under two years: analysis of 86 low and middle income countries

Neves¹,

Barros²,

Baker³

et al. 2020

Preprint

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Background Consumption of breast milk substitutes (BMS) by children aged under six months in low and middle income countries (LMICs) is directly driven by country income and family wealth. Multi-country investigations on the consumption of BMS by older children (6-23 months) are lacking. Methods Using data from 86 nationally representative surveys carried out in LMICs from 2010 onwards, we analyzed the prevalence of continued breastfeeding at one and two years, and frequency of consumption of formula and other non-human milk by age in months. Indicators were estimated through 24-hour dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socioeconomic inequalities. Results were stratified by country income groups. Findings Breastfeeding declined sharply as children became older in all LMICs, especially in upper-middle income countries. Formula consumption peaked at six months of age in low and lower-middle income countries, and at around 12 months in upper-middle income countries. Consumption of formula at any age higher in children from wealthier families in all countries, while breastfeeding was more common among poor children. Multilevel linear regression analysis showed that consumption of formula was positively associated while breastfeeding was negatively associated with absolute national income. Factors at country level explained a substantial proportion of overall variability in formula use and breastfeeding. Interpretation Infant and young child feeding practices vary strongly according to wealth, both within and between countries. Breastfeeding falls sharply as children become older, especially in wealthier families living in upper-middle income countries; this is also the group with highest formula consumption at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups in LMICs, suggesting that formula marketing at national level may be partly responsible for the observed differences.

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Section: Discussionsupporting

confidence: 52%

“…These foods are rarely explored in the IYCF literature with most available studies reporting on associations with health outcomes, such as allergy risk or child growth. 22,23…”

Section: Introductionmentioning

confidence: 99%

Consumption of breast milk, formula and other non-human milk by children aged under two years: analysis of 86 low and middle income countries

Neves¹,

Barros²,

Baker³

et al. 2020

Preprint

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“…tolerance 24,29,39,[48][49][50] and were, therefore, deemed appropriate to inform treatment efficacy. Additionally, to the best of our knowledge, there is no randomized study comparing the formula products relevant for the UK analysis.…”

Section: Journal Of Health Economics and Outcomes Researchmentioning

confidence: 99%

Cost-effectiveness Analysis of Hypoallergenic Milk Formulas for the Management of Cow’s Milk Protein Allergy in the United Kingdom

Martins

Connolly

Minshall

2021

JHEOR

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Background: Cow’s milk protein allergy (CMPA) is the most common food allergy in early childhood. In most children CMPA resolves by age 5 or 6; however, if not treated correctly can provoke nutritional deficiency resulting in poor growth. Management consists of excluding cow’s milk from the diet, with hypoallergenic formulas (or non-dairy alternatives) being introduced to meet nutritional requirements. Objectives: To compare the cost-effectiveness of hypoallergenic formulas in reducing allergic manifestations and promoting immune tolerance in infants with immunoglobulin E (IgE)-mediated symptoms of CMPA. Methods: A trial-based decision analytic cohort model was developed to simulate the occurrence of urticaria, eczema, asthma, rhinoconjunctivitis, or being symptom-free in infants with CMPA in the United Kingdom. Amino acid-based formula (AAF), extensively hydrolysed casein formula containing Lactobacillus rhamnosus Gorbach Goldin (EHCF+LGG), extensively hydrolysed whey formula (EHWF), and soy formula (SF) were compared using the National Health Service (NHS) perspective, 3-year time horizon and 3.5% discount rate for cost and health consequences. Hypoallergenic formulas comparative efficacy was sourced from a prospective cohort study. Resources required to manage allergic symptoms were sourced from published literature, validated by a UK clinician, and applied to UK cost resources. Results were reported as cost per additional child free from allergic manifestations at 3 years and cost per additional immune tolerant child at 3 years. Results: In the base case, infants receiving EHCF+LGG were associated with lower NHS resource use and improved CMPA tolerance. Over the 3-year treatment period, savings of £119, £476, and £1094 were achieved with EHCF+LGG compared to SF, EHWF and AAF, respectively. Infant formula accounted for the largest proportion of resource consumption averaging 44% for all comparators, with a minimum of 31% for SF and a maximum of 53% for AAF over 3 years. General practitioners’ visits constituted the second highest cost component, approximately 17% of total costs across comparators. The results were robust to deterministic and probabilistic sensitivity analyses. Conclusions: Compared to AAF, SF, and EHWF hypoallergenic formulas, EHCF+LGG was the most cost-effective, associated with lower total costs and contributing to a higher proportion of children being symptom-free and developing immune tolerance 3-years after diagnosis.

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“…118 The addition of specific probiotic strains, such as Lactobacillus rhamnosus GG, was found to enhance the acquisition of oral tolerance more rapidly in infants with CMA, but further studies are needed. 90,119 The presence of lactose in an EHF might be of additional benefit because of its effect on the composition of the GI microbiome through its possible prebiotic function. Lactose decreases stool pH and is associated with an increase of lactobacilli and bifidobacteria, and a decrease of potential pathogens in the GI microbiota.…”

Section: The Gastrointestinal Microbiome a Bridge Between Pathogenesis And Managementmentioning

confidence: 99%

Current Guidelines and Future Strategies for the Management of Cow’s Milk Allergy

Vandenplas¹,

Brough²,

Fiocchi³

et al. 2021

JAA

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Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them. Conclusion: A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.

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Factors Associated with the Development of Immune Tolerance in Children with Cow’s Milk Allergy

Cited by 18 publications

References 29 publications

Consumption of breast milk, formula and other non-human milk by children aged under two years: analysis of 86 low and middle income countries

Consumption of breast milk, formula and other non-human milk by children aged under two years: analysis of 86 low and middle income countries

Cost-effectiveness Analysis of Hypoallergenic Milk Formulas for the Management of Cow’s Milk Protein Allergy in the United Kingdom

Current Guidelines and Future Strategies for the Management of Cow’s Milk Allergy

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