Severe upper gastrointestinal hemorrhage due to milk protein allergy: A case report

BACKGROUND Upper gastrointestinal hemorrhage is a life-threatening manifestation of cow’s milk protein allergy(CMPA).We analyze the clinical characteristics of a case of milk protein allergy manifested as severe upper gastrointestinal hemorrhage.CASE SUMMARY The hospital admitted a 2-month-old male infant due to“melena for 6 days,he-matemesis twice”.The main symptom was melena,initially occurring once or twice per day,then gradually increasing to five or six times per day at their peak.During the course of the illness,the infant vomited blood,but there were no re-ports of vomiting,fever,pale complexion,dyspnea,wheezing,or difficulty brea-thing.Laboratory tests showed hemoglobin level of 87 g/L,platelet count of 349×109/L,and eosinophil percentage of 0.031.Coagulation studies were normal.After avoiding certain foods and feeding with an amino acid formula for 2 weeks,a repeat gastroscopy revealed less bleeding.After six weeks,a positive oral food challenge test confirmed a severe CMPA.At the 4-month follow-up,there was no gastrointestinal bleeding,and the infant was growing and developing well.CONCLUSION The manifestations of milk protein allergy are diverse and nonspecific,with gas-trointestinal bleeding being less common,especially in infants.When infants present with unexplained massive hematemesis,it’s critical to investigate the possibility of CMPA.

Very early onset perinatal constipation:Can it be cow’s milk protein allergy?

Delayed passage of meconium or constipation during the perinatal period is traditionally regarded as a signal to initiate further work up to evaluate for serious diagnoses such as Hirschsprung’s disease(HD),meconium ileus due to Cystic Fibrosis,etc.The diagnosis of HD particularly warrants invasive testing to confirm the diagnosis,such as anorectal manometry or rectal suction biopsy.What if there was another etiology of perinatal constipation,that is far lesser known?Cow’s milk protein allergy(CMPA)is often diagnosed in infants within the first few weeks of life,however,there are studies that show that the CMPA allergen can be passed from mother to an infant in-utero,therefore allowing symptoms to show as early as day one of life.The presentation is more atypical,with perinatal constipation rather than with bloody stools,diarrhea,and vomiting.The diagnosis and management would be avoidance of cow's milk protein within the diet,with results and symptom improvement in patients immediately.Therefore,we discuss whether an alternative pathway to address perinatal constipation should be further discussed and implemented to potentially avoid invasive techniques in patients.This entails first ruling out CMPA with safe,noninvasive techniques with diet modification,and if unsuccessful,then moving forward with further diagnostic modalities.

Consensus statement on the epidemiology,diagnosis,prevention,and management of cow's milk protein allergy in the Middle East:a modified Delphi-based study

Background This study aimed to develop an expert consensus regarding the epidemiology,diagnosis,and management of cow’s milk protein allergy(CMPA)in the Middle East.Methods A three-step modified Delphi method was utilized to develop the consensus.Fifteen specialized pediatricians participated in the development of this consensus.Each statement was considered a consensus if it achieved an agreement level of>80%.Results The experts agreed that the double-blind placebo-controlled oral challenge test(OCT)should be performed for 2-A weeks using an amino acid formula(AAF)in formula-fed infants or children with suspected CMPA.Formula-fed infants with confirmed CMPA should be offered a therapeutic formula.The panel stated that an extensively hydrolyzed formula(eHF)is indicated in the absence of red flag signs.At the same time,the AAF is offered for infants with red flag signs,such as severe anaphylactic reactions.The panel agreed that infants on an eHF with resolved symptoms within 2-4 weeks should continue the eHF with particular attention to the growth and nutritional status.On the other hand,an AAF should be considered for infants with persistent symptoms;the AAF should be continued if the symptoms resolve within 2-4 weeks,with particular attention to the growth and nutritional status.In cases with no symptomatic improvements after the introduction of an AAF.other measures should be followed.The panel developed a management algorithm,which achieved an agreement level of 90.9%.Conclusion This consensus document combined the best available evidence and clinical experience to optimize the management of CMPA in the Middle East.

Current status of fecal calprotectin as a diagnostic or monitoring biomarker for cow's milk protein allergy in children:a scoping review

Background There are few approved biomarkers for diagnosis and monitoring of cow's milk protein allergy(CMPA),thus the oral food challenge remains to be the golden diagnostic standard.A potential biomarker is fecal calprotectin,a cytosolic protein,elevating in the presence of intestinal mucosal inflammation.We aimed to undertake a scoping review of the evi-dence pertaining to the current status of fecal calprotectin used for diagnosis and monitoring CMPA in children,and tried to indicate the aspects needed to be concerned in the future investigations and researches.Methods A scoping review was performed using the literature searched from PUBMED,EMBASE,and Web of Science Databases until July 2019 on the studies about the application of fecal calprotectin as a biomarker of CMPA in children.Studies were examined according to the inclusion and exclusion criteria.Data were extracted,and a narrative synthesis was conducted to summarize and analyze.Results Thirteen studies with different study design embracing 1238 children were included.The age range was from infants to adolescents.Most children with CMPA presented gastrointestinal symptoms,among which hematochezia was most com-mon.Amount of data suggested that infants with CMPA represented elevated levels of fecal calprotectin,particularly with distinct significance in non-IgE-mediated CMPA groups.Decreases of fecal calprotectin after elimination diet were demon-strated in enrolled studies.However,no matter in the CMPA positive or negative groups,the changes of fecal calprotectin before or after challenge showed no significance.Contradictory results were generated from studies on the role of fecal calprotectin in predicting allergic disease.Conclusions Available evidence is not sufficient to confirm the utilization of fecal calprotectin both in diagnosis and moni-toring of CMPA and predicting for allergic disease.More clinical and bench researches with elaborate design should be conducted and the exact cut-off values of fecal calprotectin in different groups remain to be determined.

Cow’s milk-induced gastrointestinal disorders:From infancy to adulthood

Milk is related to many gastrointestinal disorders from the cradle to the grave due to the many milk ingredients that can trigger gastrointestinal discomfort and disorders.Cow’s milk protein allergy(CMPA)is the most common food allergy,especially in infancy and childhood,which may persist into adulthood.There are three main types of CMPA;immunoglobulin E(IgE)-mediated CMPA,non-IgEmediated CMPA,and mixed type.CMPA appears before the first birthday in almost all cases.Symptoms may start even during the neonatal period and can be severe enough to simulate neonatal sepsis.CMPA(often non-IgE mediated)can present with symptoms of gastroesophageal reflux,eosinophilic esophagitis,hemorrhagic gastritis,food protein-induced protein-losing enteropathy,and food protein-induced enterocolitis syndrome.Most CMPAs are benign and outgrown during childhood.CMPA is not as common in adults as in children,but when present,it is usually severe with a protracted course.Lactose intolerance is a prevalent condition characterized by the development of many symptoms related to the consumption of foods containing lactose.Lactose intolerance has four typical types:Developmental,congenital,primary,and secondary.Lactose intolerance and CMPA may be the underlying pathophysiologic mechanisms for many functional gastrointestinal disorders in children and adults.They are also common in inflammatory bowel diseases.Milk consumption may have preventive or promoter effects on cancer development.Milk may also become a source of microbial infection in humans,causing a wide array of diseases,and may help increase the prevalence of antimicrobial resistance.This editorial summarizes the common milk-related disorders and their symptoms from childhood to adulthood.

A new attempt to develop fermented milk with low whey protein allergenic potential using a top-down method

The development process of fermented milk products with low-allergenic potential usually begins with the isolation and screening of strains.However,this bottom-up screening method is time-consuming and heavy workload.Once the target strain is not screened,it will cause a waste of time and money.This experiment adopted a top-down method to screen strains quickly and efficiently and prepared a fermented milk with low whey protein allergenic potential.The traditional fermented dairy products from Xinjiang are a good source for screening functional strains.We took 59 traditional fermented dairy products from Xinjiang as samples.The antigenicity ofα-lactalbumin(α-LA)andβ-lactoglobulin(β-LG),the main allergenic proteins which are easy to cause human allergy,were taken as the indicators.Through direct screening of the fermented dairy product with the lowest antigenicity,the BZ-21 sample was selected as the target sample.The 13 strains isolated from the BZ-21 sample were safe,and the antigenicity and immunoglobulin E(IgE)-binding capacity of the fermented milk prepared under optimized fermentation conditions were reduced.The results showed that the top-down screening method used in this experiment was effective,and these 13 strains will be potential probiotics in the development of low-allergenic dairy products.