Ref Number = ASPR0046
Food Allergy / Cow's Milk Allergy and it's Manifestation in Children
Zakiudin Munasir

Pediatric Allergy - Immunology Division
Department Of Childhealth
Rumahsakit Dr. Ciptomangunkusumo
Fakultas Kedokteran Universitas Indonesia
OBJECTIVE: To understand the manifestation of food allergy/ cow's milk allergy and the role of rice protein hydrolyzed in the treatment of cow's milk allergy (CMA).

BACKGROUND: - Around 20 %  among children less than 1 year of age experience reaction againts food including food allergy
Cow?s milk protein is the second most common food allergen in young Asian children, after egg. Indonesia national data is lacking. There is some limitation of the alternative cow's milk formula, taste, price and avalaibility.


Speaking of food allergy problems, this is inseparable from the data what the incidence of food allergies. Many food allergies occur at an early age and because of the rapid increase in incidence, it is difficult to determine the exact number of events at this time. Although previously mentioned about 6 percent of children aged less than three years experience food allergies. This data may be a lower estimate than the current situation. In Australia the latest data reported that there has been a doubling in the incidence. The results of studies in Melbourne show that more than 20 percent of children are sensitive to food from the results of a skin prick test or a skin prick test on 5000 babies aged one year. Half showed reactions after provocation tests on food. This is consistent with the causes of anaphylactic reactions in preschool-aged children.
The results of a meta-analysis of the prevalence of food allergies indicate that the prevalence of food allergies reported by patients themselves is very high compared to the results of objective tests. The prevalence of self-reported food allergies varies from 1.2% to 17% for cow's milk, 0.2% to 7% for eggs, 0% to 2% for peanuts and fish, 0% to 10% for shellfish, and 3% to 35% for any food. However, the confirmed prevalence of food allergies only varies from almost 0% for fish and shellfish, 0% to 3% for milk, 0% to 1.7% for eggs, and 1% to 10.8% for any food .

The prevalence of food allergies in individuals with moderate to severe atopic dermatitis, reported to be around 30% to 40%, clinically has a significant association with food allergies treated with IgE assessed by a combination of clear symptoms, allergen skin test (SPT), serum IgE levels , oral provocation tests with food allergens suspected  or a history of direct reactions to food consumed.

As it has  mentioned above, Indonesia does not yet have national food allergy prevalence data. However, in our clinic, we found that of 42 patients with atopic dermatitis in 2013, most were sensitive to egg whites (31%), cow's milk (23.8%), chicken (23.8%), egg yolk (21 , 4%), beans (21.4%), and wheat (21.4%). A different pattern was found in our clinic in 2011, which found that the majority of our atopic dermatitis patients were sensitive to corn, followed by white eggs, tuna, chicken, cow's milk, and peanuts . Meanwhile, we also found that 3% of our diarrhea patients were allergic to cow's milk . Here we see a shift in the order of allergy-triggering foods. For example, cow's milk protein which was ranked 5th in a short time became ranks 2nd. This seems to be because the number of babies who get exclusive breastfeeding (breast milk) is decreasing so many who get cow's milk formula. This is not much different from the most common types of food allergens that have been reported globally in more than 90 per cent of children who have food allergies allergic to chicken eggs, cow's milk, soybeans, peanuts, tree nuts, wheat fish and shellfish.

Common infant presentations in food allergy/ cow?s milk allergy: Atopic dermatiti, Infantile colic, gastro-esophageal reflux and other gastro-intestinal symptoms,milk diarrhea and rectal bleeding , vomiting, chronic diarrhea, failure-to-thrive and also some respiratory symptoms. . Feeding and formula options for Infants with CMA: Breast milk with maternal diet restriction, extensively hydrolyzed formula (eHF), contains only peptides that have a MW <3,000 d, soy-based formula, free amino acid-based formula (AAF), peptide-free formulas that contain mixtures of essential and nonessential amino acids. The reasons cannot  using AA, eHF and Soy formula are  price and palatibility. Rice (Oryza sativa) is one of the most common cereals produced and consists a major source of protein in many parts of the world. An extensive rice protein-based hydrolysed formula is shown to be effective in the treatment of cow?s milk protein allergy. 

CONCLUSION: The most common manifestation of food allergy is Atopic Dermatitis, and most common food allergy in Atopic Dermatitis is Cow's Milk Allergy. Beside to treat the Atopic Dermatitis itself, to treat the CMA is also important. Cow's milk formula is alternative nutrition in baby with no breast milk. In CMA, there are some alternative cow's milk formula with some limitation. An extensive rice protein-based hydrolysed formula is shown to be effective in the treatment of cow?s milk protein allergy. Since rice is much cheaper and has a better palatability than cow?s milk-based extensive hydrolysates, and since it does not contain phytoestrogens, it may become a first option in the treatment of cow?s milk protein allergy if the efficacy and acceptability are confirmed in future studies.
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