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Diagnosis of cow's milk allergy in children: determining the gold standard?
1Hôpital Necker-Enfants Malades, Université Paris-Descartes, Paris, France.
Insights
Cow's milk protein allergy (CMPA) impacts multiple organs, causing various symptoms from colic to enterocolitis. Diagnosis involves elimination diets and oral food challenges to confirm reactions and guide management.
Area of Science:
- Allergy and Immunology
- Pediatric Gastroenterology
- Clinical Nutrition
Background:
- Cow's milk protein allergy (CMPA) is a common condition affecting infants and children.
- It can manifest with diverse symptoms impacting multiple organ systems, from the gastrointestinal tract to the skin.
- Reactions can be immediate or delayed, complicating diagnosis and management.
Purpose of the Study:
- To outline the diagnostic process for CMPA, emphasizing the role of elimination diets and oral food challenges.
- To differentiate between immediate and delayed reactions and various CMPA-related syndromes.
- To guide management strategies, including formula selection and reintroduction of milk products.
Main Methods:
- Clinical history taking and physical examination are primary diagnostic tools.
- Elimination diets followed by oral food challenges are crucial for diagnosis and treatment.
- The double-blind-placebo-controlled food challenge is the gold standard for research settings.
Main Results:
- Most CMPA cases in infants present with delayed reactions, necessitating careful diagnostic approaches.
- Accurate diagnosis involves identifying the specific syndrome, assessing risks, and choosing appropriate replacement formulas.
- Monitoring tolerance development and guiding reintroduction of milk products are key to long-term management.
Conclusions:
- Diagnosing CMPA requires a comprehensive approach beyond simple milk exclusion, focusing on clinical presentation and response to challenges.
- Management strategies should be individualized based on the child's specific condition and tolerance.
- Primary care can manage non-IgE mediated CMPA, while complex cases may require referral to specialized centers.
Abstract:
Cow's milk protein allergy (CMPA) affect many organs, from mouth to gut, with, immediate and delayed reactions, including infantile colic, food protein induced enterocolitis syndrome, enteropathy, eosinophilic disorders, among which infantile proctocolitis, and "dysmotility" disturbances, gastro-esophageal reflux and constipation. Diagnosis follows usual steps, careful history taking and medical examination, before starting an elimination diet, for diagnosis and treatment. Beyond, laboratory tests may help, but definitive conclusion will arise from the oral food challenge. The double-blind-placebo-controlled-food challenge, the "gold standard", is needed in clinical research. The food challenge includes the progressive at-home reintroduction of milk, all the more needed since most cases of CMPA in infants are delayed: in clinical practice, diagnosing CMPA is more than saying if the child reacts to cow's milk. One has to define the syndrome the child is suffering from, the risk implied, the best replacement formula. When tolerance develops, a second diagnostic procedure allows seeing if the child has outgrown his disease and, if not, what is the expected outcome and which type of food is best adapted: small amounts of milk, or transformed forms, such as baked milk. Primary care practice is adapted to non-IgE mediated CMPA. When CMPA is part of multiple food allergies or of an eosinophilic disorder, referral centers will perform multiple allergy testing, endoscopic procedures and complex dietary guidance.
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