RevPaulPediatr.2015;33(4):379---380
www.rpped.com.br
REVISTA
PAULISTA
DE
PEDIATRIA
EDITORIAL
In
time:
misuse
and
overuse
of
amino
acid
formulas
in
cow
milk
allergy
Em
tempo:
uso
indevido
e
excessivo
de
fórmulas
de
aminoácidos
na
alergia
ao
leite
de
vaca
Jon
A.
Vanderhoof
BostonChildren’sHospital,Boston,USA
Received11August2015
Allergicproctocolitis andenterocolitis havebeen success-fullytreatedwithextensivelyhydrolyzedformulasformany years.1In 1997, ourgroupand deBoissieu etal.2 inParis
reportedindependentlytwoseriesofpatientswithcowmilk proteininducedallergythatfailedtorespondtoextensively hydrolyzed formulas, but ultimately responded therapeu-tically to an amino acid-based infant formula.3 These
patientsweresubsequentlychallengedwithanextensively hydrolyzed formula and indeed their symptoms recurred, confirmingintolerancetotheextensivelyhydrolyzed prod-uct.IgEbindingepitopes havebeen demonstratedinboth extensively hydrolyzed whey and casein and are thought to be responsible for these reactions.4,5 An amino
acid-basedformulawassuccessfullyutilizedtotreateosinophilic esophagitis,confirmingthatthisdisorderisinfactanallergic processamenabletodietarytherapy.6
Thepercentageofinfantswithcowmilkproteinallergy who do not tolerate an extensively hydrolyzed formula appears be low. Traditionally, the percentage is thought to be around 5%, but some have postulated that it may be on the rise.7 Despite the low incidence of
intoler-ance to extensivelyhydrolyzed protein,the use of amino acid formulas has vastly exceeded the predicted usage in many countries, despite a significant increase in the cost of therapy. Commercial promotions and government
DOIoforiginalarticle:
http://dx.doi.org/10.1016/j.rpped.2015.08.003
E-mail:[email protected]
reimbursementpoliciesinsomeareasmayhavebeen par-tiallyresponsibleforthisphenomenon.Itisalsoquitetrue, however,thatmanycliniciansarenotawareoftheliterature supportingtheuseofextensivelyhydrolyzedandaminoacid formulas.
Aminoacidformulasaresometimesutilizedbyclinicians becausetheybelievetheclinicalresponsewillbemorerapid ortherelapseratewillbesignificantlylowerresultingina greaterdegreeofpatientsatisfaction.Thisisespeciallytrue whencosttothepatientisnotasignificantdeterrent.There havebeen norandomizedstudiesconductedtodetermine theresponseratetoanaminoacidformulaversusan exten-sivelyhydrolyzedproteinformulainallergicinfants.Severe enterocolitisisoftenthoughttobeanindicationforinitial useof an aminoacid formula, andeven recommendedin some guidelines for the management of allergicinfants.8
However,nostudieshaveeverdemonstratedincreased effi-cacyofanaminoacid-basedformulainthissituation.Amino acid-basedproductsareoftenutilizedinallergic esophagi-tisbased upon the original report demonstrating efficacy inthesepatients.Onestudy,however,usinganextensively hydrolyzedproductinadults,demonstratedapositive symp-tomaticresponse and providedan economical alternative therapy.9Nonehavebeendoneinchildren.
Istherereasonnottoutilizeaminoacidformulasinevery allergicbabyother than cost?Recently, datasuggest that someofthepeptidespresentinextensivelyhydrolyzed for-mulas,especiallythosebasedoncasein,mayfacilitatethe inductionoftolerance.10,11Specificpeptidefragmentshave
nowbeen identified that mayplay a role in thisprocess,
380 VanderhoofJA
andthis hypothesis hasbeen preliminarily verifiedin ani-malstudies.11Earlierdevelopmentoftolerancetocowmilk
proteinofcourseis amuchdesiredoutcome inthe treat-mentofallergicdisease.ItalsoappearsthatLactobacillus
GG,awell-studiedprobioticorganism(Lactobacillus rham-nosusATC51033),maysignificantlyaugmentthisprocess.12
Itispossibleotherorganismsmightdothisaswellbut fur-therresearchisneededbeforesuchstatementscanbemade withconfidence.Nonetheless,theinductionoftoleranceis akeygoalinallergymanagementandwhatevercanbedone tofacilitatethisprocessiscertainlyimportant.Oral toler-anceinductionmayalsobepossiblethroughdesensitization, andpreliminarydatalookpositivehere.13
Another issue that should be addressed is the utiliza-tionofstrategiestopreventorreducethelikelihoodofthe developmentofproteinallergyinatriskpopulations. Exten-sively hydrolyzed casein-based formulas also play a role here,andwhilenotequallyefficacious,partiallyhydrolyzed whey-based formulas may also play a role. There are howeverconflictingdatawithpartialhydrolysates.14
Inter-estingly,extensivelyhydrolyzedwhey-basedformulasdonot appeartobeeffective.15Finally,breast-feedingisan
excel-lentandcost-effectivewaytoreducetheriskofcowmilk proteinallergyinhigh-risk populations,andshouldbethe firstoptionifavailable.TheprobioticLactobacillusGGalso appears to be helpful in the situation.16 Further studies
areneeded todetermine theidealagefor introductionof proteinsintothediettopreventallergy,assome population-basedstudieshavesuggestedthatearlyintroductionmaybe ideal.17
Foodallergies,andparticularlycowmilkproteinallergy, along withother allergies andautoimmune disorders, are becomingmore commonand more significant health care issues.18Theinterventionsdiscussedhereandother
modal-ities to effectively treat and prevent food allergies will becomeincreasinglyimportantastimeprogresses.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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