Strategies and Future Opportunities for the Prevention, Diagnosis, and Management of Cow Milk Allergy

Abstract

The prevalence of food allergy has increased over the last 20-30 years, including cow milk allergy (CMA) which is one of the most common causes of infant food allergy. International allergy experts met in 2019 to discuss broad topics in allergy prevention and management of CMA including current challenges and future opportunities. The highlights of the meeting combined with recently published developments are presented here. Primary prevention of CMA should start from pre-pregnancy with a focus on a healthy lifestyle and food diversity to ensure adequate transfer of inhibitory IgG- allergen immune complexes across the placenta especially in mothers with a history of allergic diseases and planned c-section delivery. For non-breastfed infants, there is controversy about the preventive role of partially hydrolyzed formulae (pHF) despite some evidence of health economic benefits among those with a family history of allergy. Clinical management of CMA consists of secondary prevention with a focus on the development of early oral tolerance. The use of extensive Hydrolysate Formulae (eHF) is the nutrition of choice for the majority of non-breastfed infants with CMA; potentially with pre-, probiotics and LCPUFA to support early oral tolerance induction. Future opportunities are, among others, pre- and probiotics supplementation for mothers and high-risk infants for the primary prevention of CMA. A controlled prospective study implementing a step-down milk formulae ladder with various degrees of hydrolysate is proposed for food challenges and early development of oral tolerance. This provides a more precise gradation of milk protein exposure than those currently recommended.

Softer More Frequent Stools in Infants With Difficult Stooling Fed Hydrolyzed Protein Formula With Added Prebiotics: Randomized Controlled Trial

“…A further possibility is that the partial hydrolysis of cow milk proteins may potentially reduce allergenicity to a limited extent. Whereas it is widely recognized that formulas based on extensively hydrolyzed protein are the preferred choice for infants with known cow milk allergy, partial hydrolysis of cow milk protein may remove at least some of the sensitizing epitopes ( 22 ). Thus, in some infants, a partial hydrolyzate could potentially improve stooling symptoms by affecting low-grade or unrecognized cow milk allergy/sensitivity, since GI motility can be altered in response to inflammation and secretion of histamine and serotonin in allergic individuals ( 23 , 24 ).…”

Alternatives to Cow’s Milk-Based Infant Formulas in the Prevention and Management of Cow’s Milk Allergy

“…Food allergy affects ~1–3% of adults and ~6–8% of small children although the reported prevalence seems to differ between individual studies, countries, and continents [ 13 , 15 , 16 ]. The prevalence is observed to be higher in small children than in adults because many children naturally outgrow their food allergy over time, gaining tolerance to foods they were previously allergic to [ 17 , 18 ].…”

“…IgE-mediated CMA is the most common food allergy among infants and small children, affecting between 0.5 and 3.8% of the children [ 15 , 43 , 44 ]. Fortunately, most children outgrow their CMA, acquiring tolerance to cow’s milk [ 45 ], though some keep it for life [ 18 ].…”

Extensively Hydrolyzed Hypoallergenic Infant Formula with Retained T Cell Reactivity

“…In the first months after birth, breastfeeding is the ideal nutrition. For patients with confirmed IgE sensitization to cow’s milk, standard treatment recommendations are: (i) cow’s milk avoidance by strict diet, or (ii) consumption of extensively hydrolyzed hypoallergenic infant formulas or amino acid-based infant formulas [ 10 , 11 ]. For children 4 years and older with persistent cow’s milk allergy, EAACI guidelines recommend allergen immunotherapy (AIT), although no uniform AIT protocols have been established yet [ 12 ].…”