Characterization of Upper Gastrointestinal Motility in Infants With Persistent Distress and Non‐IgE‐mediated Cow's Milk Protein Allergy

Omari, Taher; Tobin, Jacinta; McCall, Lisa; Savage, Karina; Ferris, Lara; Hammond, Paul; Kritas, Stamatiki; Quinn, Patrick; Abu‐Assi, Rammy; Moore, David; Davidson, Geoffrey P.; Gold, Michael; Heine, Ralf G.

doi:10.1097/mpg.0000000000002600

Cited by 21 publications

(31 citation statements)

References 34 publications

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“…Fourteen infants (28%) had a final diagnosis of CMA, but no test showed a high predictive value. In infants on a CMA elimination diet (with AAF) there was significant improvement in GERD symptoms, oesophageal clearance and impedance baseline, all of which are considered as indirect parameters of oesophageal integrity [ 93 ].…”

Section: Hydrolysed Formulas In Gastrointestinal Motility Disordersmentioning

confidence: 99%

Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips

et al. 2021

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An allergy to cow’s milk requires the avoidance of cow’s milk proteins and, in some infants, the use of a hypoallergenic formula. This review aims to summarize the current evidence concerning different types of hydrolysed formulas (HF), and recommendations for the treatment of IgE- and non-IgE-mediated cow’s milk allergy and functional gastrointestinal disorders in infancy, for which some dietary intervention and HF may be of benefit to both immune and motor mechanisms. Current guidelines recommend cow’s milk protein (i.e., whey or casein) extensively hydrolysed formula (eHF) as the first choice for cow’s milk allergy treatment, and amino acid formulas for more severe cases or those with reactions to eHF. Rice hydrolysed formulas (rHF) have also become available in recent years. Both eHF and rHF are well tolerated by the majority of children allergic to cow’s milk, with no concerns regarding body growth or adverse effects. Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics. Despite encouraging results on tolerance acquisition, evidence is still not conclusive, thus hampering our ability to draw firm conclusions. In clinical practice, the choice of hypoallergenic formula should be based on the infant’s age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy.

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Section: Hydrolysed Formulas In Gastrointestinal Motility Disordersmentioning

confidence: 99%

Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips

et al. 2021

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“…Only one infant had positive atopy patch test, none had positive serum IgE and, surprisingly, permeability test was higher in non-CMA infants. In the group with CMA, elimination diet significantly improved GERD symptoms, esophageal clearance and baseline, indirect parameters of esophageal function and mucosal integrity [29].…”

Section: Diagnosis and Treatment Of Ger And Gerdmentioning

confidence: 87%

“…A number of studies examined the presence of CMA in infants with symptoms attributed to GERD (Table 1). The association of CMA-GERD was reported in 16-56% of cases with persistent gastrointestinal symptoms and suspicion of GERD, irrespective of breast or formula feeding [1,17,23,[27][28][29]45,62]. The percentage of infants with persistent GER symptoms with clinical improvement on diet and worsening on challenge is extremely variable depending on the population recruited, design of the study and follow up data [27].…”

Section: Literature Data On the Association Of Cma And Gerdmentioning

confidence: 99%

“…No symptom or cluster of symptoms or questionnaire showed a high sensitivity and specificity for GERD in infants and young children [34,51]. The revised infant GER questionnaire (I-GERQ-R) has a controversial diagnostic value for GERD [29,51,80] but it provides a validated tool to monitor the evolution of symptoms during an intervention trial [80].…”

Section: Diagnosis and Treatment Of Ger And Gerdmentioning

confidence: 99%

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Cow’s Milk Allergy or Gastroesophageal Reflux Disease—Can We Solve the Dilemma in Infants?

et al. 2021

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Cow’s milk allergy (CMA) and gastro-esophageal reflux disease (GERD) may manifest with similar symptoms in infants making the diagnosis challenging. While immediate reaction to cow’s milk protein indicate CMA, regurgitation, vomiting, crying, fussiness, poor appetite, sleep disturbances have been reported in both CMA and GERD and in other conditions such as functional gastrointestinal disorders, eosinophilic esophagitis, anatomic abnormalities, metabolic and neurological diseases. Gastrointestinal manifestations of CMA are often non-IgE mediated and clinical response to cow’s milk free diet is not a proof of immune system involvement. Neither for non-IgE CMA nor for GERD there is a specific symptom or diagnostic test. Oral food challenge, esophageal pH impedance and endoscopy are recommended investigations for a correct clinical classification but they are not always feasible in all infants. As a consequence of the diagnostic difficulty, both over- and under- diagnosis of CMA or GERD may occur. Quite frequently acid inhibitors are empirically started. The aim of this review is to critically update the current knowledge of both conditions during infancy. A practical stepwise approach is proposed to help health care providers to manage infants presenting with persistent regurgitation, vomiting, crying or distress and to solve the clinical dilemma between GERD or CMA.

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“…26 In infants with persistent crying, esophageal and gastrointestinal motility parameters do not reliably differentiate non-IgE-mediated CMA from functional gastrointestinal disorders or gastro-esophageal reflux disease (GERD). 27 In the group with non-IgE-mediated CMA, elimination of CMP significantly improved GER symptoms, esophageal peristaltic function, and mucosal integrity. [27][28][29] The diagnosis in clinical practice, therefore, relies on an allergy focused history and physical examination, with the resolution of symptoms with the elimination of the presumed triggering allergens.…”

Section: Diagnosismentioning

confidence: 89%

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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Characterization of Upper Gastrointestinal Motility in Infants With Persistent Distress and Non‐IgE‐mediated Cow's Milk Protein Allergy

Cited by 21 publications

References 34 publications

Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips

Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips

Cow’s Milk Allergy or Gastroesophageal Reflux Disease—Can We Solve the Dilemma in Infants?

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

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