THE MANAGEMENT OF COWS

MILK ALLERGY
INCIDENCE
Allergic Immunologic Division
Childhealth Dept Medical
Faculty UI: 4 %.
- Atopic dermatitis infants :
45 %

Diagnosis

1. Disease history
2. Daily diet record
3. Skin Prick Test
4. Specific Ig E with RAST
(Radio Allergosorbent Test)
5. Elimination and provocation test
Diet

Free of cows milk protein
Breast milk
Provides :
- Ideal nutritional, immunologic and
physiologic nourishment for all
newborn
- Components of breast milk enhance
natural defences and promote
immunoregulation

Justify the AAP and European recommendations
for exclusive and prolonged breastfeeding
Feeding and Formula Options for Infants
with CMA
Breast milk with maternal diet restriction
Soy-based formula
Extensively hydrolyzed formula (eHF)
Contains only peptides that have a MW <3,000 d
Free amino acid-based formula (AAF)
peptide-free formulas that contain mixtures of essential and
nonessential amino acids
Formulas that should NOT be used
Partially hydrolyzed formula (pHF) - Contains reduced
oligopeptides that have a MW generally <5,000 d

Greer FR, et al. Pediatrics 2008;121:183-91
Should Allergenic Foods Be
Restricted During Lactation ?
No mummy, I dont like your
hyperallergenic milk
Extensive hydrolysate CM protein
formula
Technologies to Reduce the Allergenicity of
a Protein
Enzymatic
hydrolysis
Heating
Ultrafiltration
The lower the chain length and the smaller the molecular mass, the
lower is the residual allergenicity of a protein / peptide
Protein Hydrolysates: Different
Types
Allergenicity
intact protein pHF
eHF Amino acids
Soya protein formula

As save alternative to CM formula in the
majority of infants with CM allergy after
screening documents indicate no coexisting soy
allergy


Leung et al 2003
AAP states, 'healthy full-term infants should be given soy
formula only when medically necessary,' but soy formula is still
'safe and effective' when needed.
PHYTOESTROGEN
ISSUES
ScienceDaily (Aug. 16, 2001) Philadelphia, PA -- To understand
whether hormone-like chemicals in soy products may influence sexual
development in children, researchers at the University of Pennsylvania
School of Medicine have revisited a study on soy-based infant formula
begun over thirty years ago. Their results, published in this weeks
Journal of the American Medical Association, reaffirm the safety of
soy infant formula and offer evidence against the harmful effects of
soy that have been presented in the popular media. According to their
findings, soy formula does not appear to lead to any more health or
reproductive problems than cow milk formula.
Consumption of soy formula instead of cow milk formula has no ill
effect on reproductive or endocrinologic functions in young adulthood,
said Dr. Brian L. Strom and his colleagues at the University of
Pennsylvania, Philadelphia.
The relatively high doses of isoflavones-a subcategory of
phytoestrogens-consumed by infants, fed soy formula could
theoretically impact hormone-dependent conditions such as maturation
and reproduction. Phytoestrogens are plant-based compounds that
bind to estrogen receptors in adults, and few studies have addressed
the long-term effects of significant phytoestrogen exposure. in
infancy, the researchers said.
Exposure to these phytoestrogens early in life
may have long-term health benefits
Am J Clin Nutr 1998; 68 (suppl): 1453 S-61S

Soy isoflavones estrogen agonists, antagonists
or selective estrogen receptor modulators,
depending on the conditions
Soy protein processed to contain lower levels of
isoflavones also provides significant health
benefits ( Badger TM et al, Fourth International Symposium of
soy in Preventing and Treating Chronic Disease)
Study in ChildHealth Dept.
Ciptomangunkusumo Hospital
Proportion of soy sensitization in CMA patients in this
study was 17.5%, which is similar to other studies in Asia,
and with low level of soy-specific IgE (0.48 kUA/L)
For clinical practice, soy protein could be used as an
alternative for cows milk-substitute in CMA patients
Benefecial effect soy isoflavones in
food allergy
anaphylactic symptoms
antigen specific-antibody
mast cell degranulation

Possible mechanism:
Suppression dendritic cell activation and maturation
Subsequent regulation of CD4+T cell and NK cell
function preventing over- skewing Th2 function





AMINO ACID BASE
FORMULA
20 cal/oz Formulas in the US Average cost/oz
Partially hydrolyzed whey/casein $0.15
Partially hydrolyzed soy $0.15
Extensively hydrolyzed casein
(Alimentum, Nutramigen, Pregestimil)
$0.24
Amino acid
(Elecare, Neocate)
[30 cal/oz: Neocate Jr, EO28 Splash, Elecare]
$0.34

[$0.55-0.85]
Hydrolyzed and Amino Acid-based Formulas Available in the U.S.
Milk and soy-based formulas $0.15
Stacie M. Jones, M.D.
Professor of Pediatrics
University of Arkansas for Medical Sciences
Arkansas Childrens Hospital
Guidelines for the use of infant formulas to treat cows milk
protein allergy: an Australian consensus panel opinion
Andrew S Kemp,* David J Hill,* Katrina J Allen, Kym Anderson, Geoffrey P Davidson, Andrew S
Day,Ralph G Heine, Jane E Peake, Susan L Prescott, Albert W Shugg and John K Sinn




Three types of infant formula (soy, extensively hydrolysed and
amino acid) may be appropriate for treating cows milk protein
allergy.
Selection of a formula depends on the allergy syndrome to be
treated.
Extensively hydrolysed formula is recommended as firstchoice
for infants under 6 months of age for treating
immediate cows milk allergy (non-anaphylactic), food
protein-induced enterocolitis syndrome, atopic eczema,
gastrointestinal symptoms and food protein-induced
proctocolitis.

Soy formula is recommended as first choice for infants over 6
months of age with immediate food reactions, and for those
with gastrointestinal symptoms or atopic dermatitis in the
absence of failure to thrive.
Amino acid formula is recommended as first choice in
anaphylaxis and eosinophilic oesophagitis.
If treatment with the initial formula is not successful, use of
an alternative formula is recommended

MJA 2008; 188: 109112
Budget Impact of Managing CMA
UK study of 18,350 infants with new diagnosis of
CMA
Used computer-based modeling to evaluate costs of
CMA management during first year of life
Initial Treatment: 60% soy, 18% eHF, 3% AAF
Cost estimates of managing CMA
1,381 per patient
25.6 million annually for cohort identified
Sladkevicius E, et al. J Med Economics 2010;13:119-128
Substitute Infant Formulas
Soy (confirm soy IgE negative)
<10% soy allergy among IgE-CMA
~50% soy allergy among non-IgE CMA (enterocolitis)
Cows milk protein hydrolysates
>90% tolerance in IgE-CMA
Amino acid-based formulas
Lack allergenicity
Partial hydrolysates
Not hypoallergenic!

Stacie M. Jones, M.D.
Professor of Pediatrics
University of Arkansas for Medical
Sciences
Arkansas Childrens Hospital