Children with Delayed-Type Cow's Milk Protein Allergy May Be at a Significant Risk of Developing Immediate Allergic Reactions Upon Re-introduction

Affiliations

07 March 2023

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doi: 10.2147/JAA.S400633


Abstract

Background: Cow's Milk Protein Allergy (CMPA) is the most common food allergy in children. The reaction is classified into IgE-mediated immediate reaction and delayed-onset, according to the underlying immune mechanism, and hence, the timing of the symptoms. Case reports suggest that children, with delayed CMPA reactions on elimination diet, may develop severe immediate reactions on reintroduction.

Aim: The objective of this study was to evaluate the incidence and the risk factors of developing immediate reactions to milk and dairy products in children with CMPA whose initial presentations were of delayed type.

Methods: A retrospective chart review of children, aged 0-12 years, presented with delayed type CMPA reactions to the allergy-clinical immunology clinics, was performed. The diagnosis was made clinically, and with appropriate allergy tests when indicated.

Results: Sixty children were included. Males:female ratio was 1.7:1. Family history of atopy was in 72%, and 57% had personal history of atopy. Sixty percent were not breast fed. The most common concomitant food allergy was egg. The most common initial presentation was diarrhea without protein loss or bleeding followed by exacerbation of atopic dermatitis upon exposure to dairy products. Immediate reactions developed in 21.6% upon re-exposure. There were significant associations with concomitant food allergy (OR 56.6 (3.15-1016.1) P<0.0001), especially eggs (OR 12.85 (3.09-53.5) P<0.01).

Conclusion: Children with CMPA, who present with delayed-type allergic reactions, may be at a significant risk of developing immediate reactions upon reintroduction. Evaluation of possible IgE-mediated allergic reactions before reintroduction may be advisable.

Keywords: allergy; atopy; cow’s milk protein allergy; eczema; food allergy; proctocolitis.

Conflict of interest statement

The authors report no conflicts of interest in this work.


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KMEL References


References

  1.  
    1. Hikmet T, Nacaroglu HT, Bahceci Erdem S, et al. Markers of inflammation and tolerance development in allergic proctocolitis. Arch Argent Pediatr. 2018;116(1):e1–e7. doi:10.5546/aap.2018.eng.e1 - DOI - PubMed
  2.  
    1. Lozinsky AC, Morais MB. Eosinophilic colitis in infants. J Pediatr. 2014;90(1):16–21. doi:10.1016/j.jped.2013.03.024 - DOI - PubMed
  3.  
    1. Morita H, Nomura I, Matsuda A, et al. Gastrointestinal food allergy in infants. Allergol Int. 2013;62(3):297–307. doi:10.2332/allergolint.13-RA-0542 - DOI - PubMed
  4.  
    1. Vandenplas Y. Prevention and management of cow’s milk allergy in non-exclusively breastfed infants. Nutrients. 2017;9(7):731. doi:10.3390/nu9070731 - DOI - PMC - PubMed
  5.  
    1. Luyt D, Ball H, Makwana N, et al. BSACI guideline for the diagnosis and management of cow’s milk allergy. Clin Exp Allergy. 2014;44(5):642–672. doi:10.1111/cea.12302 - DOI - PubMed
  6.  
    1. Chang A, Robison R, Cai M, Singh AM. Natural history of food-triggered atopic dermatitis and development of immediate reactions in children. J Allergy Clin Immunol Pract. 2016;4(2):229–36.e1. - PMC - PubMed
  7.  
    1. Nowak-Węgrzyn A. Food protein-induced enterocolitis syndrome and allergic proctocolitis. In: Allergy Asthma Proc. OceanSide Publications; 2015:172–184. - PMC - PubMed
  8.  
    1. Feuille E, Nowak-Węgrzyn A. Food protein-induced enterocolitis syndrome, allergic proctocolitis, and enteropathy. Curr Allergy Asthma Rep. 2015;15(8):50. - PubMed
  9.  
    1. Leonard SA, Caubet JC, Kim JS, Groetch M, Nowak-Węgrzyn A. Baked milk- and egg-containing diet in the management of milk and egg allergy. J Allergy Clin Immunol Pract. 2015;3(1):13–24. - PubMed
  10.  
    1. Flinterman AE, Knulst AC, Meijer Y, Bruijnzeel-Koomen CA, Pasmans SG. Acute allergic reactions in children with AEDS after prolonged cow’s milk elimination diets. Allergy. 2006;61(3):370–374. doi:10.1111/j.1398-9995.2006.01018.x - DOI - PubMed
  11.  
    1. David TJ. Anaphylactic shock during elimination diets for severe atopic eczema. Arch Dis Child. 1984;59(10):983–986. doi:10.1136/adc.59.10.983 - DOI - PMC - PubMed
  12.  
    1. Barbi E, Gerarduzzi T, Longo G, Ventura A. Fatal allergy as a possible consequence of long-term elimination diet. Allergy. 2004;59(6):668–669. doi:10.1111/j.1398-9995.2004.00398.x - DOI - PubMed
  13.  
    1. Meyer R, Groetch M, Venter C. When should infants with cow’s milk protein allergy use an amino acid formula? A practical guide. J Allergy Clin Immunol Pract. 2018;6(2):383–399. doi:10.1016/j.jaip.2017.09.003 - DOI - PubMed
  14.  
    1. Nocerino R, Bedogni G, Carucci L, et al. The impact of formula choice for the management of pediatric cow’s milk allergy on the occurrence of other allergic manifestations: the atopic march cohort study. J Pediatr. 2021;232:183–191.e3. doi:10.1016/j.jpeds.2021.01.059 - DOI - PubMed
  15.  
    1. Sakihara T, Otsuji K, Arakaki Y, Hamada K, Sugiura S, Ito K. Randomized trial of early infant formula introduction to prevent cow’s milk allergy. J Allergy Clin Immunol. 2021;147(1):224–232.e8. doi:10.1016/j.jaci.2020.08.021 - DOI - PubMed
  16.  
    1. D’Auria E, Salvatore S, Pozzi E, et al. Cow’s Milk Allergy: immunomodulation by Dietary Intervention. Nutrients. 2019;11(6):1399. doi:10.3390/nu11061399 - DOI - PMC - PubMed
  17.  
    1. Kiewiet MBG, Gros M, van Neerven RJJ, Faas MM, de Vos P. Immunomodulating properties of protein hydrolysates for application in cow’s milk allergy. Pediatr. Allergy Immunol. 2015;26:206–217. doi:10.1111/pai.12354 - DOI - PubMed
  18.  
    1. Wichers H. Immunomodulation by food: promising concept for mitigating allergic disease? Anal Bioanal Chem. 2009;395:37–45. doi:10.1007/s00216-009-2838-1 - DOI - PMC - PubMed
  19.  
    1. Isser JT, Lammers K, Hoogendijk A. Restoration of impaired intestinal barrier function by the hydrolysed casein diet contributes to the prevention of type 1 diabetes in the diabetes-prone BioBreeding rat. Diabetologia. 2010;53:2621–2628. doi:10.1007/s00125-010-1903-9 - DOI - PMC - PubMed
  20.  
    1. Giannetti A, Cipriani F, Indio V, et al. Influence of atopic dermatitis on cow’s milk allergy in children. Medicina. 2019;55(8):460. doi:10.3390/medicina55080460 - DOI - PMC - PubMed