Journal of Pediatrics Rev. chil. Pediatr. Vol.83 no.1 Santiago feb.

2012 Review article /REVIEW ARTICLE Allergy to milk protein of cow in the less than a year Allergy to dairy protein in children under one year old Isabel Miquel E.1, M. Eugenia Arancibia S.1 1. Infant Gastroenterology unit. Department. of Pediatrics. Santiago German clinic. Address for correspondence

ABSTRACT Food allergies are defined as an immune reaction to a protein food. It may be mediated by IgE antibodies or not, or by mixed mechanisms. During the first year of life, allergy to dairy products is the most frequent cause of food allergy. This paper reviews mechanisms and management of allergy to dairy products. Key words: Food Alergy, Dairy Protein, IgE, Infant.

OVERVIEW Defines food allergy as an adverse reaction that occurs against a food exhibition, mediated by a specific immune response and reproducible1. Food allergy can be mediated by IgE antibodies, by mechanisms of mixed or non-IgE-mediated. During the first year of life (APLV) cow's milk protein allergy is the most common form of presentation of2food allergy. This review aims to deliver a proposal to the clinical confrontation of one infant less than a year with suspicion of CMPA. Keywords: Food allergy, immunoglobulin E, lactating cow's milk protein.

Epidemiology In Chile we do not have studies of prevalence of this disease. Several European studies have estimated a range of 1.9 to 4.9% CMPA in infants under one year3.4. You suspect diagnostic CMPA This disease affects not only the patient, but also to all of his family group and environment social5. Facing a CMPA are suspected, a complete medical history and careful physical examination are essential to diagdiagnosis. In the medical history are important age of home, the type of symptoms and their frequency, time between ingestion and the onset of symptoms, details of the

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type of feeding (breast milk or formula) and a history of atopy personal and family6. The risk of atopy in a patient increases if one of the parents or twin brother have Atopic Disease (20-40%, and 25-35%, respectively). This risk increases even more if both parents are atopic (40-60%)7.8. It has been shown that feeding with exclusive breastfeeding for the first 4 to 6 months of life reduces the risk of CMPA and the majority of the manifestations of severe allergy during the period of nursing9. Not there are symptoms or signs pathognomonic of CMPA and the differential diagnosis will depend on the organs affected. Most of the time the symptoms occur after the first weeks of the introduction of cow's milk. The white bodies are: apparatus digestive (50-60%), skin (50-60%) and respiratory tract (20-30%) and may commit more than one organ in a considerable number of cases10. The frequency of anaphylaxis is estimated from 0.8 to 9%. In addition to the white body, clinical manifestations depend on the type of immune reaction involved, and may be mediated by IgE, mixed or delayed immediate-type reactions mediated by a cell mechanism. The most severe immediate reaction is anaphylaxis, occurs minutes up to two hours post exposure to the allergen. Characterized by sudden commitment to skin and/or mucous membranes, with one or more respiratory symptoms (dyspnoea, broncoespamo, stridor, hypoxemia), besides cardiovascular symptoms (hypotension, syncope), gastrointestinal symptoms (vomiting, cramps) and shock. Gastrointestinal immediate reactions include immediate gastrointestinal allergy (clinically characterized by vomiting) oral allergy syndrome. Respiratory reactions include: asthma and rhinitis secondary to ingestion or inhalation of cow's milk. Immediate dermatological reactions are: angioedema, Erythema, urticaria. Children with suspected of having presented an immediate manifestation should be referred to the immunologist. Patients with late reactions to cow's milk protein developed symptoms from hours to several days after ingestion, being more frequent gastrointestinal and dermatological manifestations. In this type of reaction the clinical presentation varies from forms mild and moderate to severe cases, which will determine the handling suggested in each patient. Clinical confrontation and management will depend on the form of presentation (moderate or severe) and the type of feeding (breast milk or formula). Suspected of CMPA in exclusively breastfed children When evaluating an infant with suspected CMPA fed exclusively on breast milk should ask family allergy history and perform a history and thorough physical examination. According to the symptoms that the patient presents, we define two sub-groups: at) suspicion of APLVleve or moderate with one or more of the following symptoms Gastrointestinal: frequent spitting up, vomiting, diarrhea, rectal bleeding, constipation (with or without perianal erythema). Skin: atopic dermatitis.

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 Other: irritability, colic abdominal (defined as pain, moan and irritability at least 3 hours per day, 3 days of the week in one period longer than 3 weeks). In these cases keep the mother, with calcium supplement (ideally calcium citrate, discarding the use of calcium gluconate), breast-feeding with elimination of milk-protein diet for two weeks which is increased to four in cases of atopic dermatitis or allergic colitis (liquid stool with mucus or blood). If the patient improves during the elimination, diet make counter-example reintroducing dairy in the maternal diet lastyou a week, if symptoms do not return considering that you there is allergy to the protein cow's milk. If symptoms return when performing the check dairy products should be eliminated maternal diet while you are breastfeeding. In the case of weaning using a highly-hydrolysed milk formula. Mother with prolonged Elimination Diet must receive nutritional advice. Start solids cooked at 6 months of age, being careful not to allergens to which the infant can have allergy. Solids should be free of milk protein up to 12 months of age and at least 6 months after the diagnosis made. If performing the contrary attributable to allergy symptoms do not occur, instruct the mother diet normal and perform continuous follow-up if symptoms reappear. On the other hand, whether to undergo elimination diet to a mother of an infant with mild to moderate symptoms suggestive of CMPA the patient does not improve, refer you to a pediatric gastroenterologist. (b) suspected of severe CMPA with one or more of the following symptoms Gastrointestinal: increase bad pondoestatural (for diarrhea, spitting up or vomiting), reject food, rectal bleeding with low hemoglobin or protein losing enteropathy. Skin: severe atopic dermatitis associated with evil increase pondoestatural. In these cases, you must refer to the gastroenterologist or pediatric dermatologist and elimination diet starting mother with supplementation of calcium (Figure 1).

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Figure 1. Algorithm for the diagnosis and management of protein allergy milk of cow (CMPA) in infants fed exclusively breast milk (LME) infant; LM = breastfeeding; FeH = extensively hydrolysed formula. CMPA suspected in infants fed with formula Like children fed to the chest detailed with an emphasis on the history of atopy, family or personal history and physical examination should be done. It could also be considered according to availability study with cutaneous test specific for cow's milk. at) suspicion of APLVleve or moderate with one or more of the following symptoms: Gastrointestinal: frequent spitting up, vomiting, diarrhea, rectal bleeding constipation (with or without perianal erythema). Skin: atopic dermatitis. Respiratory: Rhinitis, chronic cough, wheezing not associated with infections. If the infant has any of these symptoms should be formula highly hydrolyzed (with protein of whey, casein, or other) or an amino acid-based formula. If the patient does not improve after 2 to 4 weeks of elimination diet refer to the Special If you notice improvement make counter-example with milk of cow under medical observation. On the contrary not having allergy symptoms restart milk protein in the diet and track. If infants fed with formula with mild to moderate symptoms not improving and has used formula extensively hydrolyzed to test elimination diet with amino acid-based formula. To make the diagnosis of CMPA keep the Elimination Diet until 12 months or at least 6 months after the diagnosis made (b) suspected of severe CMPA with one or more of the following symptoms Gastrointestinal: increase bad pondoestatural (for diarrhea, spitting up or vomiting), reject food, secondary sideroblastic anemia to bleeding digestive macro or microscopic, protein-losing enteropathy protein (hypoalbuminemia) and protein losing enteropathy or severe allergic colitis confirmed by endoscopy and histology. Skin: severe atopic dermatitis with low serum albumin, anemia and evil increase weight. Respiratory: acute laryngeal edema or bronchial obstruction. Anaphylactic shock. In these severe cases refer to the specialist and start diet elimination with amino acid-based formula. The test of provocation in these patients should be under strict medical observation (Figure 2). On the other hand, the use of milk of other mammals such as: cow not modified, sheep, goat, Buffalo, horse or non-modified soy or rice milk is not recommended for children less than a year, since they do not cover nutritional requirements and the risk of allergic reactions cross exists11,12. Reported adverse reactions to soy in a 10-35% of infants under one year with CMPA13.

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Figure 2. Algorithm for the diagnosis and management of protein allergy milk cow (CMPA) in infants fed with formula. Diagnostic confirmation In the majority of cases the diagnosis of CMPA is based on clinical suspicion and the response of the patient to the exclusion of the suspected allergen diet. Ideally this type of empirical intervention must be confirmed by a test of provocation, to shadow the symptoms before the reintroduction of the allergen. Reference (gold standard) method is the comparative trial double-blind against placebo (DBPCC) to avoid placebo effects or subjective interpretation of tolerance or relapse14. However, in the daily clinical practice, except in very specific cases associated with severe, the confrontation is done as provocation open, i.e. that both the patient (or his family) as the treating physician are aware of the reintroduction of the allergenic protein8. To make provocation, scope (ambulatory or hospital) and the load current allergen (either progressive or fast) must be adjusted to the type of symptoms of the patient. Is recommended that tables moderate and serious, systemic symptoms, or those with possible anaphylactic reaction is suspected, tests are carried out in a hospital and with reintroduction progressive and controlled of the allergen, whereas in tables mild provocation is usually done on an outpatient basis and with dosing more rapidly growing15-17. In selected cases, except against a suspected reaction mediated by IgE request specific IgE to milk and their fractions and/or skin hypersensitivity, immediate (prick test) tests. Against suspicion of reaccionmediada by cell ask for patch testing.
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Labour received on 16 October of 2011, accepted for publication January 12, 2012.

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