Pediatricians' knowledge and practice styles regarding cow milk protein allergy among Arab countries

Cow's milk protein allergy (CMPA) affects 2-6% of children, with peak prevalence in the first year of life. Despite published guidelines, significant gaps remain in awareness and practice among healthcare providers. The aim of this study was to evaluate pediatricians' knowledge and practice styles (KPS) among pediatric care providers (PCPs) working in different Arab countries regarding their diagnosis and treatment approach to CMPA.

We conducted a cross-sectional multinational survey in eight Arab countries including Saudi Arabia, Iraq, Lebanon, Oman, Bahrain, United Arab Emirates (UAE), Qatar, and Kuwait. The following PCPs: pediatric specialists (PSs), pediatric residents (PRs), pediatric consultants (PCs), pediatric gastroenterologists (PGs), pediatric immunologists (PIs), general physicians (GPs), and family doctors (FDs) were included in this study. The survey was anonymous, and participants provided input on the diagnosis and management of CMPA.

Of the 3000 questionnaires distributed to PCPs, 2145 (response rate 72%) were completed and analyzed. The majority of the respondents were male (n = 1255; 58.5%). The majority of participants were PSs (48%). Regarding the methods to diagnose CMPA, pediatricians and non-pediatricians used clinical diagnosis (61.4%), oral elimination challenge test (27.6%), specific IgE for cow's milk (8.6%) and skin prick test (1.2%) for diagnosis of CMPA ( P < 0.001). Furthermore, pediatricians used "clinical diagnosis" method to confirm CMPA significantly more than other non- pediatricians (87% vs 13%, respectively; P < 0.001). In terms of management of CMPA in breastfed infants, 67.8% reported that continuing breastfeeding with maternal elimination of cow's milk and dairy products was the best treatment approach, with significant differences between pediatricians and non-pediatricians ( P < 0.001). In terms of management of mild-moderate CMPA in formula-fed infants, hydrolyzed formula (eHF) was the most commonly prescribed (53%), while rice-based milk was the formula least often prescribed. eHF was prescribed as a first-line treatment of CMPA significantly more frequently by pediatricians than by non-pediatricians (88.9% vs 11.1%, respectively; P < 0.001). PCPs were more likely to comply (71.1%) with European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) clinical guidelines for CMPA. PCPs were fully agreed (68.1%) to establish unified CMPA guidelines in Arab countries.

Substantial variability in pediatricians' KPS regarding CMPA across the participating Arab countries was identified. The identification of these gaps highlights the need for policymakers to develop educational materials for PCPs to increase their knowledge of CMPA. Evidence-based guidelines and standardized practice are needed in the Middle East.