Early-Life Respiratory Infections in Infants with Cow’s Milk Allergy: An Expert Opinion on the Available Evidence and Recommendations for Future Research

Fiocchi, Alessandro; Knol, Jan; Koletzko, Sibylle; O’Mahony, Liam; Papadopoulos, Nikolaos G.; Salminen, Seppo; Szajewska, Hania; Nowak‐Węgrzyn, Anna

doi:10.3390/nu13113795

Cited by 8 publications

(6 citation statements)

References 48 publications

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“…Nevertheless, the clinical finding may also occur by coincidence given the chance of non immune related skin manifestations and the high prevalence of symptoms in the respiratory tract in childhood. Nevertheless, almost 70% of children with CMA report upper respiratory tract infections [19,20]. Sorensen et al found a higher prevalence of otitis media (25 vs. 19%; <0.01; rate 0.51 vs. 0.36; <0.01) and respiratory tract infections (89% vs. 82%; rate 6.88 vs. 5.03 (<0.01) and asthma (7.1 vs. 3.8%;<0.01) [13].…”

Section: A Score As a Diagnostic Or Awareness Tool?mentioning

confidence: 99%

The Cow’s Milk Related Symptom Score: The 2022 Update

et al. 2022

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CoMiSS® was developed 7 years ago to increase the awareness of health care professionals towards the possibility that symptoms presented by infants could be related to cow’s milk. While CoMiSS was conceived mostly on theoretical concepts, data is now available from 25 clinical trials. Based on this extensive research using the tool since 2015, we aim to propose an updated CoMiSS. The evidence was reviewed, debated and discussed by 10 experts, of whom seven were part of the original group. The panel concluded that the cut-off previously proposed to indicate the likelihood that symptoms may be cow’s milk related should be lowered from ≥12 to ≥10. Data in healthy infants > 6 months are missing. Since the Brussels Infant and Toddlers Stool Scale (BITSS) was recently developed for non-toilet trained children, the Bristol Stool Scale was changed to the BITSS without changing the impact of stool characteristics on CoMiSS. Overall, CoMiSS raises awareness that symptoms might be cow’s milk related. New studies are needed to determine if the change in cut-off and other small adaptions improve its sensitivity and specificity. Data for CoMiSS is still needed in presumed healthy infants between 6 and 12 months old. There may also be regional differences in CoMiSS, in healthy infants as well as in those with cow’s milk allergy. Finally, we emphasize that CoMiSS is an awareness tool and not a diagnostic test.

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Section: A Score As a Diagnostic Or Awareness Tool?mentioning

confidence: 99%

The Cow’s Milk Related Symptom Score: The 2022 Update

et al. 2022

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“…Skin and respiratory tract manifestations occur frequently in infants with CMA and when GI and/or general manifestations are combined with skin and/or respiratory tract manifestations, the presence of CMA is more likely. 17 , 18 …”

Section: Discussionmentioning

confidence: 99%

“…Additionally, a recent retrospective study revealed that in infants under the age of two, sensitization to β-lactoglobulin (a protein found in cow’s milk) was linked to a nearly four-fold greater risk of recurrent respiratory tract infections. 18 …”

Section: Discussionmentioning

confidence: 99%

Evaluation of Cow’s Milk Related Symptom Score [CoMiSS] accuracy in cow’s milk allergy diagnosis

et al. 2023

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Background Cow’s Milk-related Symptom Score (CoMiSS) is an awareness tool to recognize cow’s milk allergy (CMA) symptoms in infants. We aimed to assess the best cut-off point of CoMiSS in our country and investigate other parameters suggested to raise the strength of CoMiSS in CMA diagnosis. Methods We enrolled 100 infants with CMA-suggestive symptoms with documentation of CoMiSS initially and 4 weeks after cow milk-free diet (CMFD) followed by an open food challenge (OFC) test. Infants with symptom recurrence upon challenge were diagnosed with confirmed CMA. Results Initial mean CoMiSS was 15.76 ± 5.29, being higher in the confirmed CMA group (84% of infants). Following CMFD, median CoMiSS significantly reduced to 1.5 in the confirmed CMA group compared to 6.5 in the negative group. Receiver operation characteristic (ROC) curve identified a CoMiSS score of ≥12 as the best cut-off value with 76.19% sensitivity, 62.50% specificity and overall accuracy of 74.00%. Mucoid stool, bloody stool and faltering growth were reported in 80, 41 and 52% of confirmed CMA infants, respectively, with considerable improvement following CMFD. Conclusions Our study revealed a CoMiSS score of ≥12 to be the best cut-off point. However, CoMiSS cannot be used alone for accurate diagnosis of CMA. Impact CoMiSS ≥12 can predict a positive response to CMFD; nevertheless, CoMiSS is a good awareness tool and cannot be regarded as a stand-alone CMA diagnostic test. CoMiSS reduction following CMFD was predictive of a reaction to OFC to diagnose CMA as well as for monitoring symptom improvement. Symptoms commonly associated with CMA as mucoid stool, bloody stool, marked abdominal distention not responding to medical treatment and faltering growth, in addition to their improvements in response to CMA are suggested parameters to be added to CoMiSS to improve its accuracy.

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“…Infants with CMA may have an increased susceptibility to infections (116). According to expert opinion in a review paper, secondary outcomes of trials suggest a trend in decreasing frequency and severity of respiratory tract (mainly) and GI infections as well as in reducing antibiotic intake in infants with CMA on an elimination diet supplemented with prebiotics, probiotics and synbiotics (116). In a retrospective study, with non‐standardized definition of CMA, GI, skin, respiratory and ear infections were reported to affect significantly more children with CMA than those without, increasing by 74% ( P < 0.001), 20% ( P < 0.001), 9% ( P < 0.001) and 30% ( P < 0.001), respectively (117).…”

Section: Clinical Gastro‐intestinal Presentation Of Cmamentioning

confidence: 99%

“…The high rate of respiratory infections in early life has a major impact on health care resources and antibiotic use with the associated risk of increasing antibiotic resistance, changes in intestinal microbiota and, consequently, on the future health of children. Infants with CMA may have an increased susceptibility to infections (116). According to expert opinion in a review paper, secondary outcomes of trials suggest a trend in decreasing frequency and severity of respiratory tract (mainly) and GI infections as well as in reducing antibiotic intake in infants with CMA on an elimination diet supplemented with prebiotics, probiotics and synbiotics (116).…”

Section: Risk For Infectious Diseasementioning

confidence: 99%

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

Vandenplas

Broekaert

Domellöf

et al. 2024

J. pediatr. gastroenterol. nutr.

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A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 1 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost and quality of life.

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Early-Life Respiratory Infections in Infants with Cow’s Milk Allergy: An Expert Opinion on the Available Evidence and Recommendations for Future Research

Cited by 8 publications

References 48 publications

The Cow’s Milk Related Symptom Score: The 2022 Update

The Cow’s Milk Related Symptom Score: The 2022 Update

Evaluation of Cow’s Milk Related Symptom Score [CoMiSS] accuracy in cow’s milk allergy diagnosis

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

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