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Intestinal malrotation with suspected cow’s milk allergy: a case report
Takuma Matsuki, Akimune Kaga, Susumu Kanda, Yutaka Suzuki, Muneyuki Tanabu, Naoya Sawa
BMC Research Notes , 2012, DOI: 10.1186/1756-0500-5-481
Abstract: The patient was a Japanese male born at 39 weeks of gestation. He was breast-fed and received commercial cow’s milk supplementation starting the day of birth and was admitted to our hospital at 6 days of age due to bilious vomiting. Plain abdominal radiography showed a paucity of gas in the distal bowel. Because we demonstrated malpositioning of the intestine by barium enema, we repositioned the bowel in a normal position by laparotomy. The patient was re-started on only breast milk 2 days post surgery because we suspected the presence of a cow’s milk allergy, and the results of an allergen-specific lymphocyte stimulation test showed a marked increase in lymphocyte response to kappa-casein. At 5 months of age, the patient was subjected to a cow’s milk challenge test. After the patient began feeding on cow’s milk, he had no symptoms and his laboratory investigations showed no abnormality. In addition, because the patient showed good weight gain and no symptoms with increased cow’s milk intake after discharge, we concluded that the present case was not the result of a cow’s milk allergy. At 1 year, the patient showed favorable growth and development, and serum allergy investigations revealed no reaction to cow’s milk.When physicians encounter infants with surgical gastrointestinal disease, including intestinal malrotation, they should consider cow’s milk allergy as a differential diagnosis or complication and should utilize food challenge tests for a definitive diagnosis.Intestinal malrotation (IM) is the incomplete rotation of the intestine during fetal development [1]. Failure to rotate leads to abnormalities in intestinal positioning and attachment that may leave obstructing bands across the duodenum and a narrow pedicle for the midgut loop, thus rendering it susceptible to volvulus. Infants affected with IM often present during the first week of life with bilious emesis. The upper gastrointestinal series is the imaging test of choice and the gold standard in the e
Evaluation of Gasteroesophageal Reflux in Infants with Cow Milk Allergy
L Atarod,Sh Bahreh-Mand,Z Kihani-Douste,A Aghamohammadi
Iranian Journal of Pediatrics , 2007,
Abstract: Background: Cow milk allergy can present as many gasteroenterological manifestations like gasteroesophageal reflux (GER). The aim of this study was to investigate the prevalence of GER in infants with CMA in Imam Khomeini Hospital (2002-2003). Methods: 51 children with CMA were evaluated. Radiographic and endoscopic assessments were performed in GER suspected cases. These cases underwent challenge test and after 2 weeks with cow milk-free diet, they were evaluated again. Findings: 5 cases (10%; 3 females and 2 males) had concomitant GER (age ranged 3-17 months, mean age: 10.6 months). 3 patients took only mother’s milk and 2 cases were fed with both mother’s milk and formula. All mothers took dairy cow products in their daily diet. Skin prick test was positive in only one infant. Interestingly, after 2 weeks of cow milk protein-free diet both allergic and GER manifestations disappeared. Conclusions: Evaluation of children with CMA for concurrent GER seems to be necessary, because treating CMA can control GER as well, suggesting an association between the two conditions. Thus an additional antireflux treatment in these patients can be prevented.
Allergy to dietary protein
Carlos Lifschitz
Pediatria Wspó?czesna , 2006,
Abstract: Definition Although it has been suggested that the term of allergy be applied only to those with immediate allergic responses to food and with the presence of specific IgE antibodies, the term allergy is loosely applied to. Among the food allergies, we include the reactions mediated by IgE (hypersensitMty or immediate type allergy), as well as those produced by any other known immunologie mechanism (reactions not mediated by IgE). Incidence Food intolerance oceurs in approximately 5% of the pediatrie population. Incidence of up to 8% have been reported. Seventy five percent of infants will have symptoms in the first two months of life. A family history of atopic diseases is fo-und in 70% of patients. Pathogenesis Because the pathogenesis and symptoms of cow milk protein intolerance (CMPI; cow milk protein sensitive entero-pathy/cow milk allergy) and those of soy milk protein intolerance are similar, we will describe them as a single entity and refer to them as dietary protein intolerance (DPI). DPI may present in infants with or without a family history of atopy or in infants with or without previous manifestations of atopy. DPI can be preceded by an episode of acute enteritis or present suddenly without any overt predisposing conditions. It is postulated that the mechanism is an allergic one and a personal and family history of atopy is often present. The-re are mor than 20 protein fractions in cow milk and p-lak-toglobulin (not present in human milk) is the commonest cul-prit but a-lactoalbumin, casein, and bovine serum albumin can also cause enteropathy. Symptoms Symptoms include: diarrhea, urticaria, eczema, rhinitis, ab-dominal pain, failure to thrive, vomiting, behavioral disturbances (erying spells, colic) and constipation. Gastrointestinal symptoms may mimie a prolonged gastroenteritis which may include vomiting, loose mucousy stools containing macro- or microscopic blood, and(or) failure to thrive. Hypoproteinemia may arise as a result of a protein-losing enteropathy. Secondary carbohydrate intolerance may oceur as a consequence of the blunting villi and depletion of the brush border disaccha-ridases. Whenever cow milk protein intolerance is suspected and a switch is mad to soy milk there is the possibility that an allergic reactions will recur. As many as 25% of children in-tolerant to cow milk react adversely to soy protein. Blood and mucus in the stools, with or without diarrhea characterizes protein-induced colitis. Proctoscopy or colono-scopywill reveal afriable mucosathat bleeds or a zone of hy-peremia around blood vessels. Biopsy may d
The usefulness of casein-specific IgE and IgG4 antibodies in cow's milk allergic children
Komei Ito, Masaki Futamura, Robert Movérare, Akira Tanaka, Tsutomu Kawabe, Tatsuo Sakamoto, Magnus P Borres
Clinical and Molecular Allergy , 2012, DOI: 10.1186/1476-7961-10-1
Abstract: Eighty-three children with suspected milk allergy (median age: 3.5 years, range: 0.8-15.8 years) were diagnosed as CMA (n = 61) or non-CMA (n = 22) based on an open milk challenge or convincing clinical history. Their serum concentrations of allergen-specific (s) IgE and IgG4 antibodies were measured using ImmunoCAP?. For the sIgG4 analysis, 28 atopic and 31 non-atopic control children were additionally included (all non-milk sensitized).The CMA group had significantly higher levels of milk-, casein- and β-lactoglobulin-sIgE antibodies as compared to the non-CMA group. The casein test showed the best discriminating performance with a clinical decision point of 6.6 kUA/L corresponding to 100% specificity. All but one of the CMA children aged > 5 years had casein-sIgE levels > 6.6 kUA/L. The non-CMA group had significantly higher sIgG4 levels against all three milk allergens compared to the CMA group. This was most pronounced for casein-sIgG4 in non-CMA children without history of previous milk allergy. These children had significantly higher casein-sIgG4 levels compared to any other group, including the non-milk sensitized control children.High levels of casein-sIgE antibodies are strongly associated with milk allergy in children and might be associated with prolonged allergy. Elevated casein-sIgG4 levels in milk-sensitized individuals on normal diet indicate a modified Th2 response. However, the protective role of IgG4 antibodies in milk allergy is unclear.Food allergies, described as adverse immune responses to food, are common and have increased in prevalence during the past decades. About 5% of the young children and 3-4% of the adults are affected today [1]. Milk, egg, peanut, tree nuts, fish, shellfish, wheat and soy are considered to cause most of the food adverse reactions [1]. Of these, cow's milk is the most frequent food causing allergy among infants and young children with a prevalence ranging from 1 to about 7.5% [2,3]. Proper management of milk allergy
Cow’s Milk Allergy Is a Major Contributor in Recurrent Perianal Dermatitis of Infants  [PDF]
Mostafa Abdel-Aziz El-Hodhod,Ahmad Mohamed Hamdy,Marwa Talaat El-Deeb,Mohamed O. Elmaraghy
ISRN Pediatrics , 2012, DOI: 10.5402/2012/408769
Abstract: Background. Recurrent perianal inflammation has great etiologic diversity. A possible cause is cow’s milk allergy (CMA). The aim was to assess the magnitude of this cause. Subjects and Methods. This follow up clinical study was carried out on 63 infants with perianal dermatitis of more than 3 weeks with history of recurrence. Definitive diagnosis was made for each infant through medical history taking, clinical examination and investigations including stool analysis and culture, stool pH and reducing substances, perianal swab for different cultures and staining for Candida albicans. Complete blood count and quantitative determination of cow’s milk-specific serum IgE concentration were done for all patients. CMA was confirmed through an open withdrawal-rechallenge procedure. Serum immunoglobulins and CD markers as well as gastrointestinal endoscopies were done for some patients. Results. Causes of perianal dermatitis included CMA (47.6%), bacterial dermatitis (17.46%), moniliasis (15.87%), enterobiasis (9.52%) and lactose intolerance (9.5%). Predictors of CMA included presence of bloody and/or mucoid stool, other atopic manifestations, anal fissures, or recurrent vomiting. Conclusion. We can conclude that cow’s milk allergy is a common cause of recurrent perianal dermatitis. Mucoid or bloody stool, anal fissures or ulcers, vomiting and atopic manifestations can predict this etiology. 1. Introduction Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area [1]. Diaper dermatitis is observed most frequently in infants at 9–12 months of age [2]. It has a multifactorial etiology and high chronicity [3, 4]. Its prevalence is not greatly different between genders or among races [5]. Signs of diaper dermatitis including erosions have been noted as early as the first 4 days of life [6–8]. There have been only a few studies on the etiology and causative factors in anal eczema [9–11]. The patient’s diet may be a factor in the development of diaper dermatitis [12]. Breastfed infants are less likely to develop moderate to severe diaper dermatitis relative to formula-fed infants [2, 13]. Adverse reactions to cow’s milk are frequent (2–7%) in the first year of life and may include cutaneous (50–60%), gastrointestinal (50–60%), or respiratory (20–30%) affection [14]. Streptococcal perianal infections were reported as a frequent cause of such a recurrent condition [15]. The aim of this work was to find out the different causes of recurrent perianal dermatitis with focus on the magnitude of cow’s milk allergy and the possible clinical or
Lymphocyte Responses to Chymotrypsin- or Trypsin V-Digested β-Lactoglobulin in Patients with Cow's Milk Allergy
Masashi Kondo, Toshiyuki Fukao, Shinji Shinoda, Norio Kawamoto, Hideo Kaneko, Zenichiro Kato, Eiko Matsui, Takahide Teramoto, Taku Nakano, Naomi Kondo
Allergy, Asthma & Clinical Immunology , 2007, DOI: 10.1186/1710-1492-3-1-1
Abstract: Cow's milk is one of the most common food allergens in the first year of life, with approximately 2 to 2.5% of infants experiencing allergic reactions to it. The majority of children outgrow their allergy to cow's milk before the age of 3 years, but 15% of infants with immunoglobulin (Ig)E-mediated cow's milk allergy retain their sensitivity into the second decade [1,2].The therapy for food allergy is a problem that is still to be resolved. The first therapeutic approach to patients with cow's milk allergy is elimination from the diet of cow's milk proteins. However, this is not always easy because cow's milk is an essential constituent of the diet or can be found in other foods as a hidden allergen. Moreover, elimination from the diet may cause nutritional imbalance.Specific allergen immunotherapy has been shown to be effective in modulating allergic responses in diseases such as rhinitis and asthma [3,4]. However, the ability of whole cow's milk to crosslink mast cell-bound IgE, resulting in anaphylactic reaction, has limited the application of rush immunotherapy with intact cow's milk.A possible immunotherapeutic approach to cow's milk allergy would be the use of hydrolyzed or enzymatically digested peptides of cow's milk, which can induce immunomodulation by T-cell response but which do not cause IgE-mediated reactions. Even the use of hydrolyzed or digested peptides can cause IgE-mediated reactions if IgE epitopes are still present in the digested peptides. On the other hand, T-cell epitopes may not be retained by hydrolysis or digestion. In the latter case, no immunomodulation is expected.Generally, IgE antibodies to the various allergen components in cow's milk proteins (such as casein and whey proteins) are present in patients with cow's milk allergy. One of the major allergens in cow's milk is β-lactoglobulin (BLG). It has no homologous counterpart in human milk. In rodents, partially hydrolyzed whey protein and trypsin-digested BLG induced specific immunol
Use of Donkey Milk in Children with Cow’s Milk Protein Allergy  [PDF]
Paolo Polidori,Silvia Vincenzetti
Foods , 2013, DOI: 10.3390/foods2020151
Abstract: Human breast milk is the best nutritional support that insures the right development and influences the immune status of the newborn infant. However, when it is not possible to breast feed, it may be necessary to use commercial infant formulas that mimic, where possible, the levels and types of nutrients present in human milk. Despite this, some formula-fed infant develops allergy and/or atopic disease compared to breast-fed infants. Cow’s milk allergy can be divided into immunoglobulin IgE mediated food allergy and non-IgE-mediated food allergy. Most infants with cow’s milk protein allergy (CMPA) develop symptoms before 1 month of age, often within 1 week after introduction of cow’s milk-based formula. Donkey milk may be considered a good substitute for cow’s milk in feeding children with CMPA since its composition is very similar to human milk. Donkey milk total protein content is low (1.5–1.8 g/100 g), very close to human milk. A thorough analysis of the donkey milk protein profile has been performed in this study; the interest was focused on the milk proteins considered safe for the prevention and treatment of various disorders in humans. The content of lactoferrin, lactoperoxidase and lysozyme, peptides with antimicrobial activity, able to stimulate the development of the neonatal intestine, was determined. Donkey milk is characterized by a low casein content, with values very close to human milk; the total whey protein content in donkey milk ranges between 0.49 and 0.80 g/100 g, very close to human milk (0.68–0.83 g/100 g). Among whey proteins, α-lactalbumin average concentration in donkey milk is 1.8 mg/mL. The results of this study confirmed the possibility of using donkey milk in feeding children with CMPA.
Oral desensitization in children with IgE-mediated cow's milk allergy: a prospective clinical trial
Mansouri M,Movahhedi M,Pourpak Z,Akramian R
Tehran University Medical Journal , 2007,
Abstract: Background: Cow's milk protein allergy (CMPA) is the most common food allergy during the first year of life. Strict avoidance of specific foods is the only accepted treatment for food-induced allergic reactions. This is often an unrealistic therapeutic option, since cow's milk is a basic food that is extensively used in infant formula. The recent preliminary experience of oral desensitization to cow's milk by Meglio & Patriarca seems promising. The object of this study was to investigate the desensitization of children with CMPA to cow's milk.Methods: All the patients referred to the Allergology Department of the Children's Medical Center Hospital, Tehran from March 2004 to November 2005 suspected to have CMPA were evaluated. The patients were included in the intervention or control groups of the study. For the intervention group, Meglio's protocol was performed. We observed and examined the control group for at least 6 months. Eventually both groups were reevaluated for the symptoms and persistence of positive specific IgE for cow milk proteins.Results: We enrolled 20 patients for oral desensitization and 13 patients were enrolled in the control group. Both groups were similar with regard to the mean age, sex and clinical symptoms. In 18 (90%) of the intervention subjects, oral desensitization with cow's milk was successfully performed. The entire protocol was completed by 14 (70%) of the intervention subjects. At the end of the six-month observation period, all the patients in the control group were still symptomatic after ingestion of cow's milk. The levels of specific IgE for cow's milk in the intervention group decreased significantly, which was not observed in the control group.Conclusion: We successfully desensitized 90% of our CMPA patients. Considering that all the patients in the control group remained symptomatic after the period of observation and our promising results in oral desensitization with cow's milk, we can safely propose this protocol as a hopeful alternative in the treatment of CMPA. We speculate that oral desensitization to cow's milk does not alter the natural outcome of CMPA, but substantially increases the threshold dose necessary to elicit allergic symptoms.
Cow's milk protein allergy in children: a practical guide
Carlo Caffarelli, Francesco Baldi, Barbara Bendandi, Luigi Calzone, Miris Marani, Pamela Pasquinelli, on behalf of EWGPAG
Italian Journal of Pediatrics , 2010, DOI: 10.1186/1824-7288-36-5
Abstract: The report prepared by the study group was discussed by members of Working Groups who met three times in Italy. This guide is the result of a consensus reached in the following areas. Cow's milk allergy should be suspected in children who have immediate symptoms such as acute urticaria/angioedema, wheezing, rhinitis, dry cough, vomiting, laryngeal edema, acute asthma with severe respiratory distress, anaphylaxis. Late reactions due to cow's milk allergy are atopic dermatitis, chronic diarrhoea, blood in the stools, iron deficiency anaemia, gastroesophageal reflux disease, constipation, chronic vomiting, colic, poor growth (food refusal), enterocolitis syndrome, protein-losing enteropathy with hypoalbuminemia, eosinophilic oesophagogastroenteropathy. An overview of acceptable means for diagnosis is included. According to symptoms and infant diet, three different algorithms for diagnosis and follow-up have been suggested.Cow's milk protein allergy (CMPA) affects from 2 to 6% of children, with the highest prevalence during the first year of age [1]. About 50% of children have been shown to resolve CMPA within the first year of age, 80-90% within their fifth year [2,3]. The rate of parent-reported CMPA is about 4 times higher than the real one in children [4]. So, many children are referred for suspected CMPA based on parent perception, symptoms such as cutaneous eruption, insomnia, persistent nasal obstruction, sebhorreic dermatitis or positive results to unorthodox investigations. Moreover, parents often put their children on unnecessary diet without an adequate medical and dietary supervision. These inappropriate dietary restrictions may provoke nutritional unbalances, especially in the first year of age. Therefore, an accurate diagnosis of CMPA is important in order to avoid not only the risk of rickets, decreased bone mineralization [5], anaemia, poor growth and hypoalbuminemia, but also that of immediate clinical reactions or severe chronic gastroenteropathy leadi
Gut Microbiota as Potential Therapeutic Target for the Treatment of Cow’s Milk Allergy  [PDF]
Roberto Berni Canani,Margherita Di Costanzo
Nutrients , 2013, DOI: 10.3390/nu5030651
Abstract: Cow’s milk allergy (CMA) continues to be a growing health concern for infants living in Western countries. The long-term prognosis for the majority of affected infants is good, with about 80% naturally acquiring tolerance by the age of four years. However, recent studies suggest that the natural history of CMA is changing, with an increasing persistence until later ages. The pathogenesis of CMA, as well as oral tolerance, is complex and not completely known, although numerous studies implicate gut-associated immunity and enteric microflora, and it has been suggested that an altered composition of intestinal microflora results in an unbalanced local and systemic immune response to food allergens. In addition, there are qualitative and quantitative differences in the composition of gut microbiota between patients affected by CMA and healthy infants. These findings prompt the concept that specific beneficial bacteria from the human intestinal microflora, designated probiotics, could restore intestinal homeostasis and prevent or alleviate allergy, at least in part by interacting with the intestinal immune cells. The aim of this paper is to review what is currently known about the use of probiotics as dietary supplements in CMA.
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