When Should Infants with Cow's Milk Protein Allergy Use an Amino Acid Formula? A Practical Guide
Rosan Meyer1, Marion Groetch2, Carina Venter3
1Imperial College, Department of Paediatrics, London, United Kingdom.
Insights
Cow's milk protein allergy (CMPA) affects young children, often requiring hypoallergenic formulas like extensively hydrolyzed formula (EHF) or amino acid formula (AAF). AAFs may be necessary for persistent symptoms, growth issues, or severe allergic conditions.
Area of Science:
- Pediatric Allergy and Immunology
- Gastroenterology
- Clinical Nutrition
Background:
- Cow's milk protein allergy (CMPA) is a prevalent childhood condition, frequently diagnosed in infants under one year.
- Hypoallergenic formulas, including extensively hydrolyzed formula (EHF) and amino acid formula (AAF), are essential when breast milk is not an option.
- While EHF suffices for many, a subset of children with CMPA benefit from AAF, though its use involves significant cost considerations.
Purpose of the Study:
- To critically review the evidence supporting the use of amino acid formula (AAF) in specific pediatric populations with cow's milk protein allergy (CMPA).
- To provide healthcare professionals with an evidence-based guide for the appropriate selection of AAF in managing CMPA.
- To delineate scenarios where AAF is indicated beyond EHF, considering factors like symptom persistence, growth, and severity of allergic reactions.
Main Methods:
- Systematic literature review and critical analysis of published data.
- Evaluation of identified themes for AAF indication, including symptom resolution, growth faltering, multiple food eliminations, and specific allergic conditions.
- Assessment of current guidelines and evidence for AAF use in eosinophilic esophagitis and anaphylaxis.
Main Results:
- Amino acid formula (AAF) may be indicated for height growth faltering in infants with CMPA.
- Children requiring AAF often exhibit multisystem involvement, multiple food eliminations, and severe gastrointestinal allergies.
- Current recommendations support AAF as a first-line treatment for eosinophilic esophagitis and for anaphylaxis due to potential severe reactions.
Conclusions:
- The use of AAF in CMPA is justified in specific cases, particularly those with persistent symptoms, growth failure, or severe allergic manifestations like eosinophilic esophagitis and anaphylaxis.
- While AAF is beneficial for certain severe CMPA cases, breast-feeding should always be supported.
- This review offers a practical, evidence-based framework for healthcare providers to guide AAF selection in pediatric CMPA management.
Abstract:
Cow's milk protein allergy (CMPA) is the most common food allergy in childhood and its prevalence ranges between 1.9% and 4.9%. Most children present with CMPA at age less than 1 year and therefore may require a hypoallergenic formula in the absence of breast milk. Hypoallergenic formulas include both extensively hydrolyzed formula (EHF) and amino acid formula (AAF). For most children with a CMPA, an EHF will be sufficient for symptom resolution, as reflected in current guidelines, but there is a subset of children with CMPA where an AAF may be indicated. The appropriate use of an AAF is a highly debated topic, because there is a significant fiscal burden to either the health care system or the parents. From the literature, the following themes were identified as possible reasons for choosing an AAF: (1) symptoms not fully resolved on EHF, (2) faltering growth/failure to thrive, (3) multiple food eliminations, (4) severe complex gastrointestinal food allergies, (5) eosinophilic esophagitis, (6) food protein-induced enterocolitis syndrome, (7) severe eczema, and (8) symptoms while breast-feeding. Each of these themes was critically reviewed using all available published data and found that using an AAF in height growth faltering may be indicated. In addition, patients who end up on an AAF often present with multisystem involvement, requiring multiple food eliminations and fall within the more severe spectrum of gastrointestinal allergies. In eosinophilic esophagitis, all current recommendations support the use of an AAF as first-line approach, and in children with anaphylaxis, despite limited evidence an AAF is recommended because of the potential risk for a severe reaction. The use of an AAF in children who are breast-fed remains a highly controversial topic and at all times breast-feeding should be supported in children with CMPA. This article provides a practical guide that is evidence based for health care professionals to the use of AAF.
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