COW’S MILK ALLERGY IN INFANTS AND CHILDREN- DIETARY ADVANCEMENT

Cow's milk allergy (CMA) is the most common food allergy in young children but is  uncommon in adults. This food allergy presents with a wide range of clinical syndromes due to immunologic responses to cow's milk proteins that can be immunoglobulin E (IgE) and/or non-IgE mediated. CMA does not include other adverse reactions to milk, such as lactose intolerance, which are non-immune mediated.

Issues of cross-reactivity among milk of different mammalian species (such as sheep and goat) are addressed here. This topic also reviews various aspects of management of milk allergy, including instructions about avoidance of milk protein, replacement of milk with alternative protein and calcium sources, education in the proper management of accidental exposures, and monitoring for resolution of the allergy. The epidemiology, pathogenesis, clinical features, and diagnosis of milk allergy are discussed separately. Most patients with cow's milk allergy (CMA) do not tolerate milk from sheep and goats, and they are unlikely to tolerate milk from deer, ibex, and buffalo as well. However, some patients with CMA may tolerate milk from other mammals, such as camels, pigs, reindeer, horses, and donkeys.

Mammals that are phylogenetically related, such as cow and water buffalo, sheep and goat, and horse and donkey, have similar milk protein expression. In vitro studies have shown extensive cross-reactivity between milk from cows, sheep, and goats but only weak cross-reactivity with proteins from donkeys and mares. Significant amino acid sequence homology and a resulting high rate of clinical cross-reactivity between milk from ruminants (eg, approximately 90 percent of children with immunoglobulin E [IgE]-mediated CMA react to goat's milk) make milk from sheep and goats inappropriate feeding alternatives for most CMA individuals. However, some patients with primary goat's or sheep's milk allergy may tolerate cow's milk

Co-sensitization assessed by skin testing to deer's, ibex's (wild mountain goat), and buffalo's milk is common in patients with CMA, but positive skin tests to camel's and pig's milk are uncommon. There is also only partial cross-reactivity between cow's milk and reindeer's milk beta-lactoglobulins in patients with CMA. However, studies on clinical tolerability of these alternative mammalian milks are missing.

EPINEPHRINE – AN AUTOINJECTOR FOR INFANTS AND TODDLERS

Epinephrine is the drug of choice in the treatment of anaphylaxis and is available in many parts of the world in the form of epinephrine autoinjectors for self-treatment [1]. However, when prescribing these devices, clinicians must teach patients how and when to use them and dispel fears about adverse effects. Autoinjectors may be lifesaving for patients but only if patients are willing and able to use these devices effectively.

Children with serious allergies require access to injectable epinephrine, but the standard dose available in Pediatric Autoinjectors (0.15 mg) is relatively high for infants and small toddlers. To deliver an ideal dose to infants, some clinicians dispense an ampule of epinephrine and a syringe, although this approach requires significant caregiver training. A lower-dose epinephrine Autoinjector that delivers 0.1 mg has been developed (Auvi-q), which is labelled for use in infants and toddlers 7.5 to 15 kg (16.5 to 33 lbs), and may be an easier option for some families.

Epinephrine is a sympathomimetic agent with multiple actions that can reverse the symptoms of anaphylaxis.

Beneficial effects — Epinephrine acts as an agonist at alpha-1 receptors to mediate increased vasoconstriction, increased peripheral vascular resistance, and decreased mucosal edema. Agonist effects at beta-2 receptors result in bronchodilation and decreased mediator release from mast cells and basophils

Adverse effects — Even when injected properly, epinephrine is often associated with minor and transient adverse effects such as tremor, dizziness, palpitations, anxiety, restlessness, and headache

INTRODUCING HIGHLY ALLERGENIC FOODS TO INFANTS AND CHILDREN

Studies support the existence of a critical time early in infancy during which the genetically predisposed atopic infant is at higher risk for developing allergic sensitization. Thus, dietary interventions in the first years of life have been analyzed for their effects on the prevalence of allergic disease including food allergy. Both American and European allergy expert committee guidelines recommend that solid foods be introduced between four to six months of age in all infants. Other organizations have also concluded that complementary foods may be safely introduced between four and six months of age, although many still recommend or prefer exclusive breastfeeding for the first six months of life. Recommendations regarding when to introduce highly allergenic foods, particularly in high-risk infants, have shifted over time.

While any food has the potential to cause allergy, certain foods are more common triggers of significant acute allergic reactions due to various factors. The most common food allergens in children in the United States and many other countries include cow's milk (CM), hen's egg, soy, wheat, peanut, tree nuts, and seafood. The American Academy of Pediatrics (AAP) had previously suggested in 2000 that the introduction of certain highly allergenic foods be delayed further in high-risk children: cow's milk (CM) until age one year; eggs until age two years; and peanuts, tree nuts, and fish until age three years. This recommendation was based upon early studies that suggested that delayed introduction of solid foods might help prevent some allergic diseases, particularly atopic dermatitis.

The most prevalent allergic or atopic disorders include atopic dermatitis (AD), asthma, Allergic Rhinitis (AR), and food allergies. These conditions afflict 20 percent of the population of the United States, and their prevalence appears to be increasing in developed nations. The increase in atopic diseases has been recognized as a pandemic, thus emphasizing the need for effective allergy prevention.