Cow’s milk allergy: towards an update of DRACMA guidelines

Abstract

BackgroundIn 2010, the diagnosis and treatment of IgE-mediated CMA were systematized in a GRADE guideline.Objectives & methodsAfter 6 years, the state of the knowledge in diagnosis and treatment of CMA has largely evolved. We summarize here the main advances, and exemplify indicating some specific points: studies aimed at better knowledge of the effects of breastfeeding and the production of new special formulae intended for the treatment of CMA. The literature (PubMed/MEDLINE) was searched using the following algorithms: (1) [milk allergy] AND diagnosis; (2) [milk allergy] AND [formul*] OR [breast*], setting the search engine [6-years] time and [human] limits. The authors drew on their collective clinical experience to restrict retrieved studies to those of relevance to a pediatric allergy practice.ResultsSeveral clinical studies did address the possibility to diagnose CMA using new tools in vitro and in vivo, or to diagnose it without any evaluation of sensitization. Some studies also addressed the clinical role of formulae based on milk hydrolysates, soy, or rice hydrolysates in the treatment of CMA. Many studies have elucidated the effects of selective nutrients in breastfed infants on their immunologic and neurologic characteristics.ConclusionsEvidence-based diagnostic criteria should be identified for non-IgE-mediated CMA. Debate is ongoing about the best substitute for infants with CMA. In particular, Hydrolyzed Rice Formulae have been widely assessed in the last six years. In the substitute choice, clinicians should be aware of recent studies that can modify the interpretation of the current recommendations. New systematic reviews and metanalyses are needed to confirm or modify the current DRACMA recommendations.

Alergia alimentaria en pediatría: recomendaciones para su diagnóstico y tratamiento. Texto completo

“…Algunos niños pueden sufrir aversión por alimentos o inapetencia (gastroenteropatías eosinofílicas). 79,80 En lactantes con APLV, la LM es indicación; la madre es quien realizará la DE, 81 controlando su nutrición si es por lapsos prolongados. Cuando no son amamantados, necesitan un sustituto de leche nutricionalmente adecuado y tolerado 82,83 (Anexo,…”

“…La leche de cabra y de oveja no se indica como reemplazo: 95% reaccionan y presenta alto contenido de proteínas (sobrecarga de solutos al riñón) y escasas vitaminas B12-B9 (necesita ser enriquecida). 81 Las leches de equinos (yegua, burra) demostraron tolerancia del 82%; su composición es cercana a la leche humana (grandes cantidades de ácidos grasos esenciales). Podrían ser consideradas como sustitutos en APLV no IgE-mediada.…”

“…Podrían ser consideradas como sustitutos en APLV no IgE-mediada. 81 Se encuentran panalergenos en proteínas transportadoras de lípidos, resistentes al calor y a pepsina, que causan reacciones aun cuando se ingieren cocidos. Predominan en las pieles y cubiertas de frutas y verduras.…”

World Allergy Organization Journal: the Editors Look Back at 2016

“…Among them, milk allergy is a specific concern in children. Besides IgE-mediated, the importance of non-IgE mediated cow’s milk allergy has gained tremendous attention and the urgent need for evidence-based criteria on it was articulated in a call for an update on the DRACMA guidelines [20]. Importantly, current substitution strategies were discussed in this constantly changing field, accompanied by thoughts on food processing methods.…”

What’s next for DRACMA?

“…dealing with it and to the presence of different guidelines and position papers. For these reasons and for the accruing evidence on diagnosis and treatment of CMA, the update of DRACMA guidelines is necessary [23].…”