Cow’s milk protein allergy is common in infants from industrialised countries, but is rarely considered in developing countries due to its variable clinical presentation.
We report on a Tanzanian male infant, who developed blood-stained stool when feeding fresh cow’s milk at the age of three months. After an initial diagnosis of amoebiasis, possible cow’s milk protein allergy was suspected. Further diagnostic work-up was not possible due to lack of resources. After elimination of cow’s milk from the diet, the infant recovered soon.
Cow’s milk protein allergy should be considered more frequently in infants from developing countries, especially when they belong to agropastoralist tribes and are fed cow’s milk early.
BACKGROUND AND OBJECTIVES:
Infantile colic is a common problem among young infants. Cow’s milk allergy has been suggested as one of the causes. We aimed to investigate the value of the cow’s milk skin test for the diagnosis of cow’s milk allergy in exclusively breast-fed infants with infantile colic.
Exclusively breast-fed infants with infantile colic were enrolled in this study. On the first visit, the average hours of crying of the infant in a 24-h period were recorded and the cow’s milk skin test was performed. If the infant had a positive skin test, elimination of cow’s milk from the mothers’ diet was advised. Infants with negative skin tests were divided into case and control groups. Cow’s milk was eliminated from the diet of mothers in the case group. After 2 weeks, the number of hours of crying were recorded again. The reduction in the crying hours was compared between the two groups using the chi-square test.
Skin tests were positive in 3 of 114 cases (2.6%) of infantile colic. All three cases recovered completely following elimination of cow’s milk from the mother’s diet. Among the 111 patients with negative skin tests, 77 patients completed the study: 35 in the case group and 42 in the control group. The reduction in crying hours in infants in the case group was not significantly different from that in the control group.
Elimination of cow’s milk from the mothers’ diet is not beneficial for infants with a negative skin test. Infants with a positive skin test may benefit from this management.
Fetal midgut volvulus is quite rare, and most cases are associated with abnormalities of intestinal rotation or fixation. We report a case of midgut volvulus without malrotation, associated with a meconium pellet, during the gestation period. This 2.79 kg, 33-wk infant was born via a spontaneous vaginal delivery caused by preterm labor. Prenatal ultrasound showed dilated bowel loops with the appearance of a ‘coffee bean sign’. This patient had an unusual presentation with a distended abdomen showing skin discoloration. An emergency laparotomy revealed a midgut volvulus and a twisted small bowel, caused by complicated meconium ileus. Such nonspecific prenatal radiological signs and a low index of suspicion of a volvulus during gestation might delay appropriate surgical management and result in ischemic necrosis of the bowel. Preterm labor, specific prenatal sonographic findings (for example, the coffee bean sign) and bluish discoloration of the abdominal wall could suggest intrauterine midgut volvulus requiring prompt surgical intervention.
Midgut volvulus; Coffee bean sign; Meconium ileus
Early introduction of whole cow’s milk may lead to iron deficiency anemia. From a nutritional point of view, it is best to delay the introduction of whole cow’s milk until the infant is one year old. While there is no evidence to suggest adverse clinical sequelae associated with the increased renal solute load in healthy infants, feeding with whole cow’s milk would narrow the margin of safety in situations that may lead to dehydration. Early exposure to cow’s milk proteins increases the risk of developing allergy to milk proteins. Because of the possible association between early exposure to cow’s milk proteins and risk for type 1 diabetes mellitus, breast-feeding and avoidance of commercially available cow’s milk and products containing intact cow’s milk protein during the first year of life are strongly encouraged in families with a strong history of insulin dependent diabetes mellitus. The authors suggest that the optimal food in infancy is human breast milk. If human milk is not available, it is preferred that iron-fortified formulas rather than whole cow’s milk be used during the first year of life.
whole cow’s milk; infancy
Abnormalities in midgut rotation occur during the physiological herniation of midgut between the 5th and 10th week of gestation. The most significant abnormality is narrow small bowel mesentery which is prone to volvulus. This occurs most frequently in the neonatal period, less commonly midgut malrotation presents in adulthood with either acute volvulus or chronic abdominal symptoms. It is the latter group that represents a diagnostic challenge. We report a case of a 17-year-old male patient who presented with 10-year history of nonspecific gastro-intestinal symptoms. After extensive investigation the patient was diagnosed with midgut malrotation following computed tomography of abdomen. The patient was treated with a laparoscopic Ladd's procedure and at 3 months he was gaining weight and had stopped vomiting. A laparoscopic Ladd's procedure is an acceptable alternative to the open technique in treating symptomatic malrotation in adults. Midgut malrotation is a rare congenital anomaly which may present as chronic abdominal pain. Abdominal CT is helpful for diagnosis.
Congenital; Malrotation; Midgut
Intestinal malrotation occurs when there is a disruption in the normal embryological development of the bowel. The majority of patients present with clinical features in childhood, though rarely a first presentation can take place in adulthood. Recurrent bowel obstruction in patients with previous abdominal operation for midgut malrotation is mostly due to adhesions but very few reported cases have been due to recurrent volvulus. We present the case of a 22-year-old gentleman who had laparotomy in childhood for small bowel volvulus and then presented with acute bowel obstruction. Preoperative computerised tomography scan showed small bowel obstruction and features in keeping with midgut malrotation. Emergency laparotomy findings confirmed midgut malrotation with absent appendix, abnormal location of caecum, ascending colon and small bowel. In addition, there were small bowel volvulus and a segment of terminal ileal stricture. Limited right hemicolectomy was performed with excellent postoperative recovery. This case is presented to illustrate a rare occurrence and raise an awareness of the possibility of dreadful recurrent volvulus even several years following an initial Ladd’s procedure for midgut malrotation. Therefore, one will need to exercise a high index of suspicion and this becomes very crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality.
Gut volvulus; Intestinal malrotation; Acute bowel obstruction; Computerised tomography scan; Laparotomy
Milk processing technologies for the control of cow’s milk protein allergens are reviewed in this paper. Cow’s milk is a high nutritious food; however, it is also one of the most common food allergens. The major allergens from cow’s milk have been found to be β-lactoglobulin, α-lactalbumin and caseins. Strategies for destroying or modifying these allergens to eliminate milk allergy are being sought by scientists all over the world. In this paper, the main processing technologies used to prevent and eliminate cow’s milk allergy are presented and discussed, including heat treatment, glycation reaction, high pressure, enzymatic hydrolysis and lactic acid fermentation. Additionally, how regulating and optimizing the processing conditions can help reduce cow’s milk protein allergenicity is being investigated. These strategies should provide valuable support for the development of hypoallergenic milk products in the future.
Cow’s milk protein; Allergen; Milk processing; Control technologies
Intestinal malrotation in neonates or infants may require urgent surgical treatment, especially when volvulus and vascular compromise of the midgut are suspected. Successful laparoscopic management of malrotation has been described in a number of case reports. It remains unclear, however, whether laparoscopy for the treatment of malrotation has a success rate equal to that of open surgery and what relative risks exist in terms of conversion and redo surgery in larger numbers of patients. This report describes a retrospective analysis of the clinical outcome for 45 children who underwent laparoscopic treatment of intestinal malrotation at the authors’ institution.
The 45 patients in this series, ages several days to 13 years, underwent a diagnostic laparoscopy for suspected intestinal malrotation. For 37 patients, malrotation with or without volvulus was diagnosed. All these patients underwent laparoscopic derotation and Ladd’s procedure.
Successful laparoscopic treatment of intestinal malrotation could be performed in 75% of the cases (n = 28), and conversion to an open procedure was necessary in 25% of the cases (n = 9). The median hospital stay was 11 days (range, 2–60 days). Postoperative clinical relapse due to recurrence of malrotation, volvulus, or both occurred for 19% of the laparoscopically treated patients (n = 7). These patients underwent laparoscopic (n = 1) or open (n = 6) redo surgery.
Diagnostic laparoscopy is the procedure of choice when intestinal malrotation is suspected. If present, malrotation can be treated adequately with laparoscopic surgery in the majority of cases. Nevertheless, to prevent recurrence of malrotation or volvulus, a low threshold for conversion to an open procedure is mandated.
Gastrointestinal surgery; Laparoscopy; Malrotation; Neonates
Reche M, Pascual C, Fiandor A, Polanco I, Rivero-Urgell M, Chifre R, Johnston S, Martín-Esteban M. The effect of a partially hydrolysed formula based on rice protein in the treatment of infants with cow’s milk protein allergy. Pediatr Allergy Immunol 2010: 21: 577–585. © 2010 John Wiley & Sons A/S
Infants diagnosed with allergy to cow’s milk protein (CMP) are fed extensively hydrolysed cow’s milk formulas, modified soy formulas or even amino acid-based formulas. Hydrolysed rice protein infant formulas have become available and have been shown to be well tolerated by these infants. A prospective open, randomized clinical study to compare the clinical tolerance of a new hydrolysed rice protein formula (HRPF) with an extensively hydrolysed CMP formula (EHF) in the feeding of infants with IgE-mediated cow’s milk allergy. Ninety-two infants (46 boys and 46 girls, mean age 4.3 months, range 1.1–10.1 months) diagnosed with IgE-mediated cow’s milk allergy were enrolled in the study. Clinical tolerance to the formula products was tested. Clinical evaluation included skin prick tests with whole cow’s milk, soya and rice as well as antigens of CMP (beta-lactoglobulin, alpha-lactalbumin, casein and bovine seroalbumin), HRPF and EHF and specific IgE determinations to CMP using CAP technology. Patients were randomized to receive either an EHF based on CMP or a new HRPF. Follow-up was at 3, 6, 12, 18 and 24 months. Growth parameters were measured at each visit. One infant showed immediate allergic reaction to EHF, but no reaction was shown by any infant in the HRPF group. The number of infants who did not become tolerant to CMP during the study was not statistically different between the two groups. Measurement of IgE levels of infants allergic to CMP during the study showed no significant differences between the two formula groups. Growth parameters were in the normal range and similar between groups. In this study, the HRPF was well tolerated by infants with moderate to severe symptoms of IgE-mediated CMP allergy. Children receiving this formula showed similar growth and development of clinical tolerance to those receiving an EHF. In accordance with current guidelines, this HRPF was tolerated by more than 90% of children with CMP allergy and therefore could provide an adequate and safe alternative to CMP-hydrolysed formulas for these infants.
cow’s milk protein allergy; hydrolysed rice protein formula; extensively hydrolysed cow’s milk protein formula
Allergic proctocolitis (APC) in exclusively breast-fed infants is caused by food proteins, deriving from maternal diet, transferred through lactation. In most cases a maternal cow milk-free diet leads to a prompt resolution of rectal bleeding, while in some patients a multiple food allergy can occur. The aim of this study was to assess whether the atopy patch test (APT) could be helpful to identify this subgroup of patients requiring to discontinue breast-feeding due to polisensitization. Additionally, we assessed the efficacy of an amino acid-based formula (AAF) when multiple food allergy is suspected. amino acid-based formula
We have prospectively enrolled 14 exclusively breast-fed infants with APC refractory to maternal allergen avoidance. The diagnosis was confirmed by endoscopy with biopsies. Skin prick tests and serum specific IgE for common foods, together with APTs for common foods plus breast milk, were performed. After a 1 month therapy of an AAF all patients underwent a follow-up rectosigmoidoscopy.
Prick tests and serum specific IgE were negative. APTs were positive in 100% infants, with a multiple positivity in 50%. Sensitization was found for breast milk in 100%, cow's milk (50%), soy (28%), egg (21%), rice (14%), wheat (7%). Follow-up rectosigmoidoscopy confirmed the remission of APC in all infants.
These data suggest that APT might become a useful tool to identify subgroups of infants with multiple gastrointestinal food allergy involving a delayed immunogenic mechanism, with the aim to avoid unnecessary maternal dietary restrictions before discontinuing breast-feeding.
allergic proctocolitis; food allergy; breast feeding; patch test
To provide a practical, evidence-based approach to the diagnosis and management of milk protein allergy in infants.
SOURCES OF INFORMATION
MEDLINE was searched from 1950 to March 2008 using the MeSH heading milk-hypersensitivity. Additional sources were derived from reviews found with the initial search strategy. Evidence was levels I, II, and III.
Milk protein allergy is a recognized problem in the first year of life; cow’s milk protein allergy is the most common such allergy. Diagnosis is suspected on history alone, with laboratory evaluations playing a supporting role. Confirmation requires elimination and reintroduction of the suspected allergen. Management includes diet modification for nursing mothers and hydrolyzed formulas for formula-fed infants. Assessing the underlying immunopathology can aid in determining prognosis.
The therapeutic model presented allows rapid assessment of the presence of allergy, timely management, and surveillance for recurrence of symptoms. Breastfeeding can be continued with attentive diet modification by motivated mothers.
Cow's milk allergy (CMA) is the most common food allergy. Clinical manifestations are mediated immediate hypersensitivity and delayed. The allergy study include: specific IgE, prick and patch test. Regarding treatment, this is based on the exclusion diet and the replacement of cow's milk hydrolysates extensive.
Virtually all infants who have cow's milk allergy develop this condition in the first year of life, with clinical tolerance developing in about 80 percent by their fifth birthday.
Describe the case of a child with CMA, which moves without tolerance and also become sensitized to other foods.
Female with 6 years of age. At 9 months presents watery diarrhea, weight loss and intermittent rash. Initial study (2006): Upper endoscopy: Duodenitis chronic nonspecific, total IgE: 72.60 IU/mL, IgE specific to cow's milk 10.40 IU/mL (Class III) and prick test positive. Exclusion diet starts to cow's milk, its derivatives and beef. Patient improvement. At 2 years, begins with rhinitis and diarrhea reappears with low weight. Colonoscopy (2007): Subacute nonspecific colitis histology. At 3 years old facial angioedema, throat and rash are associated with eating chicken, turkey, carrot and orange juice. New tests: specific IgE cow's milk, 24. 7 IU/mL (class IV), class II chicken. Prick test positive. At 4 years enter kindergarten, restarts with diarrhea and occasional angioedema. Cow's milk specific IgE (January 2009): 66, 6 IU/mL (class V). January 2010: 5 years post anaphylactic shock milk pudding. Besides diarrhea 10 times a day, intermittently throughout the year. Year 2011: intermittent diarrhea and specific IgE to cow's milk is kept in class V.
In this case the patient with CMA which evolved atypically because it has not been able to acquire tolerance. Moreover, awareness is added to other foods during their evolution. A recent study indicated a lower rate of development of clinical tolerance. As assessed by passing a milk challenge, 5 percent were tolerant at age 4 and 21 percent at age 8. Patients with persistent milk allergy have higher cow's milk sIgE levels in the first 2 years of life. Approximately 35 percent developed allergy to other foods.
Cow’s milk allergy (CMA) affects 2% to 3% of young children and presents with a wide range of immunoglobulin E (IgE-) and non-IgE-mediated clinical syndromes, which have a significant economic and lifestyle impact. Definitive diagnosis is based on a supervised oral food challenge (OFC), but convincing clinical history, skin prick testing, and measurement of cow’s milk (CM)-specific IgE can aid in the diagnosis of IgE-mediated CMA and occasionally eliminate the need for OFCs. It is logical that a review of CMA would be linked to a review of soy allergy, as soy formula is often an alternative source of nutrition for infants who do not tolerate cow’s milk. The close resemblance between the proteins from soy and other related plants like peanut, and the resulting cross-reactivity and lack of predictive values for clinical reactivity, often make the diagnosis of soy allergy far more challenging. This review examines the epidemiology, pathogenesis, clinical features, natural history and diagnosis of cow’s milk and soy allergy. Cross-reactivity and management of milk allergy are also discussed.
cow’s milk; soy; bovine; allergy; cross-reactivity; diagnosis; management; natural history; pediatric; children
The relationships between a history of egg or cows' milk allergy, positive skin tests to these allergens, and atopic illness were examined in a sample of 126 children. Positive skin tests were found more often in children with a history of egg or cows' milk allergy than in children with no such history. 40 children suspected of being allergic to egg or milk, by history or by positive skin tests, were tested by double-blind food challenge. 54 challenges were given to these children, and 26 (49%) were positive. Children suspected of being allergic to egg had a greater incidence of positive challenges than children suspected of having milk allergy. Children with both a present history of food allergy and a positive skin test for that allergen were more likely to have positive challenges than children having only one of these indicators. Most children with positive challenges failed to satisfy Goldman's criterion of a minimum of three positive challenges because of the severity of their reactions. Less stringent criteria are needed for the diagnosis of food allergy in children who are particularly sensitive to food allergens.
Appendicitis is a common surgical condition with various clinical presentations. The diagnosis could be obscured by underlying undiagnosed anatomical anomalies like intestinal malrotation. Intestinal malrotation is a rare foetal anomaly resulting from an incomplete, or failure of midgut rotation and fixation. 85% of cases have been estimated to present in the first two weeks of life. Presentation at adulthood is rare. In cases where peritonism is elicited elsewhere other than the right iliac fossa, clinicians should bear in mind the possibility of underlying intestinal malrotation, as this could be the first presentation of this rare congenital condition.
Cow's milk is the most common food allergen in infants and the diagnosis of cow's milk allergy is difficult, even with the use of several diagnostic tests. Therefore, elimination diets and challenge tests are essential for the diagnosis and treatment of this disorder. The aim of this study is to report the clinical presentation and nutritional status of children evaluated by pediatric gastroenterologists for the assessment of symptoms suggestive of cow's milk allergy.
An observational cross-sectional study was performed among 9,478 patients evaluated by 30 pediatric gastroenterologists for 40 days in 5 different geographical regions in Brazil. Clinical data were collected from patients with symptoms suggestive of cow's milk allergy. The nutritional status of infants (age ≤ 24 months) seen for the first time was evaluated according to z-scores for weight-for-age, weight-for-height, and height-for-age. Epi-Info (CDC-NCHS, 2000) software was used to calculate z-scores.
The prevalence of suspected cow's milk allergy in the study population was 5.4% (513/9,478), and the incidence was 2.2% (211/9,478). Among 159 infants seen at first evaluation, 15.1% presented with a low weight-for-age z score (< -2.0 standard deviation - SD), 8.7% with a low weight-for-height z score (< -2.0 SD), and 23.9% with a low height-for-age z score (< -2.0 SD).
The high prevalence of nutritional deficits among infants with symptoms suggestive of cow's milk allergy indicates that effective elimination diets should be prescribed to control allergy symptoms and to prevent or treat malnutrition.
To study the age when symptoms of adverse reactions to milk occur, in premature and term children, the debut of various symptoms, immunoglobulin E (IgE)- and non-IgE-mediated reactions and the frequency of tolerance at 1 year.
Six hundred and eight children, 193 premature and 416 term infants, were followed. Symptomatic children were invited to a clinical examination. The criteria for the diagnosis were: histories of suspected cow's milk allergy (CMA) and proven IgE-mediated reactions to cow's milk or positive elimination/challenge tests.
Twenty-seven out of 555 (4.9%) were diagnosed with adverse reactions to cow's milk. All had symptoms before 6 months of age. The main symptoms were: pain behaviour (13), gastrointestinal symptoms (7), respiratory symptoms, (6) and atopic dermatitis (1). One child had proven IgE to cow's milk. Premature and term infants displayed the same symptoms and age of debut. Thirteen children were tolerant to cow's milk at 1 year.
ConclusionAdverse reactions to milk start early in life, with pain behaviour, gastrointestinal, and respiratory symptoms being the most common, and rarely atopic dermatitis. Non-IgE-mediated reactions were the most frequent. Symptoms and age of debut were the same in premature and term infants. Half of the children tolerated cow's milk at age 1.
Adverse reactions to milk; Infancy; Premature children
Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.
Malrotation; Laparoscopic surgery; Ladd procedure; Acute abdomen; Teenager
Cow’s milk allergy is the most common food allergy in young children. In areas outside the United States, milk from other mammals has been studied as a possible and desirable alternative for children with cow’s milk allergy.
We chose to further investigate water buffalo’s milk as an alternative for cow’s milk allergic children in the United States.
Children with cow’s milk allergy were skin prick tested with water buffalo’s milk. Additionally, subjects were followed clinically for 1 year after the test to determine how many of the subjects had persistent cow’s milk allergy.
In total, 30 children, age 8 months to 8 years, were skin prick tested to water buffalo’s milk with 73% (22/30) having a positive test. All children with a negative water buffalo’s milk skin test also had a negative cow’s milk skin test. In follow-up, most (7 of 8) of the children with a negative skin prick test (SPT) to water buffalo’s milk were found to have outgrown their cow’s milk allergy. In comparison, all of the subjects with a positive skin test to water buffalo’s milk had persistent cow’s milk allergy. After adjusting for this, we determined that 96% (22/23) of the children with persistent cow’s milk allergy were positive on skin testing to water buffalo’s milk.
In this population, the vast majority of children with persistent cow’s milk allergy were positive on skin prick testing to water buffalo’s milk. These results indicate that water buffalo’s milk is unlikely to be a successful alternative for children with cow’s milk allergy.
Malrotation of the midgut is generally regarded as paediatric pathology with the majority of patients presenting in childhood. The diagnosis is rare in adults, which sometimes leads to delay in diagnosis and treatment. A high index of suspicion is therefore required when dealing with patients of any age group with abdominal symptoms. We present a case of a 55-year old man who presented with an acute abdomen with preoperative computed tomography scan and operative findings confirming midgut rotation. The duodenum, small bowel, caecum and appendix were abnormally located, with the presence of classical Ladd's bands. There was no evidence of intestinal volvulus. The patient underwent an emergency laparotomy with an uneventful postoperative recovery.
A review of the literature is presented to highlight the rarity of intestinal malrotation and the controversies surrounding its management in the adult population.
Midgut malrotation; acute abdomen; Ladd's bands; computed tomography scan; laparoscopy
Congenital midgut malrotation is rarely encountered outside the pediatric population. The Ladd's procedure is the standard corrective measure for intestinal malrotation in children and consists of division of peritoneal bands (Ladd's bands) traversing the posterior abdomen, reduction of volvulus, appendectomy, and functional postioning of the intestine with or without fixation. Clinical manifestations of malrotation and results of Ladd's procedure have been described in adults, but laparoscopic treatment remains to be established as adequate treatment.
Records were reviewed of 7 patients, ages 17 to 45, all with a history of abdominal discomfort dating from childhood or early adolescence. The diagnosis of malrotation was made by barium small bowel examination in all cases. Symptoms consisted of recurrent bouts of abdominal pain that were most often postprandial, with bloating and, less frequently, constipation. Surgical treatment consisted of laparoscopic exploration via 4 ports. Peritoneal bands were completely divided, and an appendectomy performed in all patients. Three patients required reduction of nonstrangulated chronic midgut volvulus.
No early complications occurred, and all patients were discharged on postoperative days 1 through 3. At 2 months to 48 months after surgery, 1 patient had been lost to follow-up. Five patients (71%) reported substantial improvement in abdominal discomfort, with only occasional mild symptoms. Constipation continued in 1 patient, but required less aggressive treatment. One patient reported only slight improvement in postprandial abdominal pain.
Although rarely encountered, intestinal malrotation after childhood can produce significant clinical symptoms that respond to surgical treatment. The results of the present series indicate that laparoscopic Ladd's procedure is an acceptable alternative to the open technique in treating symptoms of intestinal malrotation in adults.
Intestinal malrotation; Ladd's procedure; Laparoscopy
The 1-hour xylose absorption test was evaluated as method for the diagnosis of cows' milk protein-sensitive enteropathy in a prospective study of 48 infants with diarrhoea clinically suspected to be due to intolerance of cows' milk. The infants were maintained on a lactose and cows milk protein-free diet for 6-8 weeks and then were challenged with cows' milk protein. Jejunal biopsies and the 1-hour xylose absorption test were performed immediately before and 20-24 hours after cows' milk provocation. After milk provocation, 30 infants had clinical, enzymological, and histological relapse, and in 28 of them there was a significant depression of post-provocation blood xylose levels. Six infants had histological and enzymological relapse but clinically they tolerated cows' milk. The post-provocation blood xylose level was depressed in all infants. Ten infants had enzymological relapse without histological or clinical relapse. The post-challenge blood xylose was depressed significantly (greater than 20%) in 3, mildly depressed in 3 (16-18%), and not depressed in four. Two infants clinically, histologically, and enzymologically tolerated cows' milk; in each the post-challenge xylose was depressed (22%, 12%). It appears that the 1-hour blood xylose test is not as reliable as the jejunal biopsy in the diagnosis of cows' milk protein-sensitive enteropathy.
Occasionally, exclusively breastfed infants with cow’s milk allergy (CMA) remain symptomatic despite strict maternal milk avoidance.
To determine whether or not persistence of symptoms could be due to sensitization against endogenous human milk proteins with a high degree of similarity to bovine allergens.
Ten peptides representing known bovine milk IgE-binding epitopes [α-lactalbumin (ALA), β- and κ-casein] and the corresponding, highly homologous human milk peptides were labelled with sera from 15 breastfed infants with CMA, aged 3 weeks to 12 months, and peptide (epitope)-specific IgE antibodies were assessed. Nine of the 15 breastfed infants became asymptomatic during strict maternal avoidance of milk and other major food allergens; six infants remained symptomatic until weaned. Ten older children, aged 5–15 years, with CMA were also assessed. The functional capacity of specific IgE antibodies was assessed by measuring β-hexosaminidase release from rat basophilic leukaemia cells passively sensitized and stimulated with human and bovine ALA. Results A minimum of one human milk peptide was recognized by IgE antibodies from 9 of 15 (60%) milk-allergic infants, and the majority of older children with CMA. Genuine sensitization to human milk peptides in the absence of IgE to bovine milk was occasionally seen. There was a trend towards specific IgE being detected to more human milk peptides in those infants who did not respond to the maternal milk elimination diet than in those who did (P = 0.099). Functional IgE antibody to human ALA was only detected in infants not responding to the maternal diet.
Conclusions and Clinical Relevance
Endogenous human milk epitopes are recognized by specific IgE from the majority of infants and children with CMA. Such autoreactive, human milk-specific IgE antibodies appear to have functional properties in vitro. Their role in provoking allergic symptoms in infants exclusively breastfed by mothers strictly avoiding dietary milk remains unclear.
atopic eczema; autoreactivity; cow’s milk allergy; cross-reactivity; endogenous protein; human milk; IgE antibodies; infants; RBL assay; sensitization; SPOT method
Intestinal malrotation is well covered in the surgical literature from the point of view of operative management, but few reviews to date have attempted to provide a comprehensive examination of the topic from the point of view of aetiology, in particular genetic aetiology. Following a brief overview of molecular embryology of midgut rotation, we present in this article instances of and case reports and case series of intestinal malrotation in which a genetic aetiology is likely. Autosomal dominant, autosomal recessive, X-linked and chromosomal forms of the disorder are represented. Most occur in syndromic form, that is to say, in association with other malformations. In many instances, recognition of a specific syndrome is possible, one of several examples discussed being the recently described association of intestinal malrotation with alveolar capillary dysplasia, due to mutations in the forkhead box transcription factor FOXF1. New advances in sequencing technology mean that the identification of the genes mutated in these disorders is more accessible than ever, and paediatric surgeons are encouraged to refer to their colleagues in clinical genetics where a genetic aetiology seems likely.
Intestinal malrotation; FOXF1; Genetics; Embryology
A joint study group on cow's milk allergy was convened by the Emilia-Romagna Working Group for Paediatric Allergy and by the Emilia-Romagna Working Group for Paediatric Gastroenterology to focus best practice for diagnosis, management and follow-up of cow's milk allergy in children and to offer a common approach for allergologists, gastroenterologists, general paediatricians and primary care physicians.
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.