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CLINICAL NUTRITION HIGHLIGHTS Science Supporting Better Nutrition 2010 • Volume 6, Issue 3 ISSN 1815-7262 CLINICAL NUTRITION HIGHLIGHTS Science supporting better nutrition 2010 • Volume 6, Issue 3 In this issue Diagnosing and treating cow’s milk protein allergy Clinical nutrition abstracts 32nd ESPEN Congress CLINICAL NUTRITION HIGHLIGHTS Science supporting better nutrition 2010 • Volume 6, Issue 3 Feature article 2 Diagnosing and treating cow’s milk protein allergy Professor Christophe Dupont Health economic perspective 8 Economic estimates of the burden of cow’s milk protein allergy: A literature review Clinical nutrition abstracts 9 Cancer 9 Critical care 9 Geriatrics 12 Immunonutrition 13 Nutrition support 14 Pediatrics 15 Highlights of 32nd ESPEN Congress 18 5–8 September 2010 Conference calendar 24 Sponsored as a service to the medical profession by the Nestlé Nutrition Institute. Editorial development by CMPMedica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. Although great care has been taken in compiling and checking the information herein to ensure that it is accurate, the editor, publisher and sponsor shall not be responsible for the continued currency of the information or for any errors, omissions or inaccuracies in this publication. © 2010 Société des Produits Nestlé S.A. All rights reserved. No part of this publication may be reproduced by any process in any language without the written permission of the publisher. Diagnosing and treating cow’s milk protein allergy Professor Christophe Dupont Pediatric Gastroenterology Feature article Feature Hôpital Necker – Enfants Malades Paris, France I. Introduction mendations or guidelines for the diagnosis and treatment of CMPA; one such task force was convened to develop Cow’s milk is the basis of most infant formulas, is widely consensus recommendations, including an algorithm, to used for complementary feeding and is commonly consumed specifically assist primary care physicians and general pedia- throughout childhood as part of a “balanced” diet. Cow’s tricians.1 This article will review these recommendations, milk protein (CMP) can be the cause of adverse reactions which were based on a comprehensive review of the liter- in children, affecting organs such as the skin, gastrointes- ature and existing national recommendations and standards, tinal (GI) tract and respiratory system. The range of clinical as well as the clinical experience and consensus opinion of manifestations extends from the well-recognized immuno- the consensus panel members. globulin E (IgE)-mediated allergies, usually with immediate onset, to a wide array of non–IgE-mediated allergies, usually with delayed onset. Symptoms range from GI symptoms II. Symptoms of CMPA to chronic eczema. Cow’s milk protein allergy (CMPA) is therefore easily missed in primary care settings where it is Symptoms of CMPA are numerous, and were classified by not usually considered as a cause of such symptoms as infant the consensus panel for better understanding according to distress or constipation. The mainstay of CMPA treatment is severity, referred to as ‘alarm symptoms’, or frequency, as avoidance of CMP. A careful prescription and explanation of shown in Tables 1 and 2, respectively.1 Symptoms of CMPA the elimination diet is required for caregivers to ensure that may cluster according to certain patterns. potential nutritional compromise is prevented. The long-term consequences of potential nutritional deficiencies from CMPA are unknown. Iron deficiency seems to occur frequently, with the presence of iron deficiency Accurate and early diagnosis Table 1. Alarm symptoms and findings (can be found alone or in combination with items listed in table 2), indicating severe of CMPA will reduce the number CMPA as the possible cause Organ involvement Symptoms and findings Gastrointestinal tract Failure to thrive due to chronic diarrhea of infants on inappropriate and/or refusal to feed and/or vomiting Iron deficiency anemia due to occult or elimination diets and decrease macroscopic blood loss Hypoalbuminemia Endoscopic/histologically confirmed the risk of complications, such as enteropathy or severe colitis Skin Exudative or severe atopic dermatitis with impaired growth hypoalbuminemia or failure to thrive or iron deficiency anemia Respiratory tract Acute laryngoedema or bronchial (unrelated to infection) obstruction with difficulty breathing Accurate and early diagnosis of CMPA will reduce the General Anaphylaxis number of infants on inappropriate elimination diets and Reproduced from Guidelines for the Diagnosis and Management of Cow’s Milk Protein Allergy in Infants, Vandenplas Y, et al, Arch Dis Child volume 92, pages 902-908, 2007, with permission from decrease the risk of complications, such as impaired growth. BMJ Publishing Group Ltd. CMPA, cow’s milk protein allergy. CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 6, Volume CLINICAL NUTRITION HIGHLIGHTS • 2010 Several working parties have therefore developed recom- 2 2 Table 2. Most frequent symptoms of CMPA* IgE-mediated food allergy to egg, CMP and/or peanuts. During the episode of eczema, the causal role of an impaired Organ involvement Symptoms skin barrier increases the likelihood of allergen sensitization Gastrointestinal tract Frequent regurgitation Vomiting via the cutaneous route. Diarrhea In gut eosinophilic disorders the key characteristic Constipation (with/without perianal rash) article Feature is eosinophilic infiltration, which can lead to eosinophilic Blood in stool Iron deficiency anemia esophagitis (EE). This occurs more frequently in boys than Skin Atopic dermatitis in girls, and is manifested by nausea, dysphagia sometimes Swelling of lips or eye lids (angioedema) with food impaction, vomiting and epigastric pain or eosino- Urticaria unrelated to acute infections, philic gastroenteritis; symptoms overlap those of other intes- drug intake or other causes tinal diseases. Pediatric patients with eosinophilic GI diseases Respiratory tract Runny nose (otitis media) (unrelated to infection) Chronic cough have evidence of food allergy, especially to cow’s milk and Wheezing egg. The role of aeroallergen sensitivity, particularly in EE, General Persistent distress or colic (wailing/ is determined by variations in the eosinophilic content of the irritable for ≥3 h per day) at least 3 days/ esophageal mucosa according to season. week over a period of >3 weeks Reproduced from Guidelines for the Diagnosis and Management of Cow’s Milk Protein Allergy in Infants, Vandenplas Y, et al, Arch Dis Child volume 92, pages 902-908, 2007, with permission from Non–IgE-mediated disorders BMJ Publishing Group Ltd. * Infants with CMPA in general show one or more of the listed symptoms. Non–IgE-mediated disorders affect mainly young infants, CMPA, cow’s milk protein allergy. are commonly isolated to the GI tract, and are more chronic in nature. anemia in some cases leading to a diagnosis of CMPA, as Food protein-induced proctocolitis is considered a well as failure to thrive. type of eosinophilic GI disorder, but involves only a non– IgE-mediated mechanism. It is generally present in the first few months of life, due to food proteins passing from the III. Categories of allergic reactions maternal breast milk.3,4,6 These infants suffer from rectal to CMP bleeding but appear healthy and are growing well. The diagnosis requires colonoscopy, which shows mucosal edema Diagnosing CMP-induced adverse reactions requires a clear with stripes of mucosa exhibiting bleeding and clusters of understanding of the immunological basis for their classi- eosinophilic infiltration. Symptoms resolve spontaneously by fication, with diagnostic modalities varying according to the age of 1 year. classification.2-5 Food protein-induced enterocolitis syndrome (FPIES) is most commonly seen in infants during the first 3 months of IgE-mediated symptoms life, but its development might be delayed in breastfed babies. Immediate GI hypersensitivity or “gastrointestinal anaphy- Ingestion of CMP triggers severe symptoms of prolonged laxis” affects both infants and children, with acute onset of projectile vomiting that develop within a few hours after nausea and colicky abdominal pains within a few minutes feeding. During long-term or intermittent ingestion of and up to 2 hours after food ingestion.2-4 Diarrhea may milk, infants may experience severe vomiting and diarrhea follow several hours after consumption of CMP in associ- that can lead to dehydration, lethargy, acidosis and methe- ation with other target organ responses (eg, urticaria and moglobinemia with high peripheral leukocyte counts; the bronchial asthma), as well as during systemic anaphylaxis infants may appear to have sepsis. Oral challenge should be in atopic patients. performed with caution because about 20% of reactions lead to shock.3,4,7 Mixed IgE-mediated and cell-mediated Food protein-induced enteropathy usually presents Issue 3 6, Volume CLINICAL NUTRITION HIGHLIGHTS • 2010 disorders and/or ”eosinophilic in the first few months of life with non-bloody diarrhea, gastroenteropathies” steatorrhea, malabsorption, and failure to thrive. Protein CMP “sensitive” eczema or atopic eczema is a chronic inflam- losing enteropathy may lead to edema, abdominal distension matory skin disorder associated with raised serum IgE in two and anemia. The differential diagnosis must consider thirds of cases, allergen sensitization and a family history of other causes of enteropathy, including
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