Glauce Hiromi Yonamine

Double-blind, placebo-controlled food challenges in Brazilian children: Adaptation to clinical practice

BACKGROUND A double-blind, placebo-controlled food challenge (DBPCFC) is considered the gold standard for diagnosing food allergy, but because of methodological difficulties it is rarely conducted in clinical practice, especially in paediatric patients. The purpose of the study was to propose a DBPCFC protocol that is adapted to our conditions for the diagnosis of an IgE-mediated cows milk allergy (CMA) in a Brazilian reference centre for paediatric allergies. METHODS This study includes the experimental phase (choice of materials, adjustments made to protocols described in the literature) and the test execution phase. DBPCFCs were performed in 58 patients aged 1-15 years who were separated into two groups: Group 1 (n=39), sex 1.6 M:F, 5.3 years median age, suggestive history of IgE-mediated CMA; and Group 2 (n=19), sex 1.4 M:F, 8.3 years median age with symptoms not associated with milk ingestion and laboratory data not compatible with IgE-mediated CMA. RESULTS The materials were standardised for testing: containers and disposable products, low-lactose cows milk (CM) and vehicles, such as natural fruit juice, vegetable soup and soybean-based beverages. Each DBPCFC was performed in a single day with two blind, randomised phases with a 2-h interval between them. The milk doses were gradually increased and offered in regular intervals of 15-30 min. Following negative or inconclusive results, patients underwent an open oral challenge test with 200 mL of low-lactose CM. CONCLUSIONS The proposed adaptation for the DBPCFC allowed to implement this important test for the diagnosis of IgE-mediated CMA in a reference centre for paediatric allergies. It was considered feasible and safe if performed in an appropriate setting with physician supervision.

Baked milk tolerant patient: Is there any special feature?

BACKGROUND Determining whether patients with cows milk allergy (CMA) can tolerate foods produced with baked milk could provide a better quality of life, a better prognosis, and an option for desensitization. OBJECTIVES The aim of this study was to identify which patients over four years of age with persistent CMA could tolerate baked milk, to compare the clinical and laboratory characteristics of reactive and non-reactive groups and to describe their clinical evolution. MATERIALS AND METHODS A cross-sectional study was conducted (January/13 to November/14) that included all the patients followed at a food allergy center who met the inclusion criteria. The patients underwent an oral food challenge (OFC) with a muffin (2.8g of cows milk protein). To exclude cows milk (CM) tolerance, the patients were subsequently challenged with unheated CM. RESULTS Thirty patients met all the inclusion criteria. Fourteen patients (46.7%) were considered non-reactive to baked milk and reactive to unheated CM. When the groups that were reactive and non-reactive to baked milk were compared, no statistically significant differences in clinical features were found. The prick test for α-lactalbumin (p=0.01) and casein (p=0.004) and the serum specific IgE for casein (p=0.05) presented statistical differences. After one year, none of the patients who were reactive to baked milk were ingesting CM, while 28% of the tolerant patients were consuming fresh CM (p=0.037). CONCLUSIONS Baked milk can be tolerated by patients with CMA, especially those with lower levels of casein and α-lactalbumin. This option can improve quality of life and accelerate tolerance.

Correction to: Rate and determinants of non-adherence to a gluten-free diet and nutritional status assessment in children and adolescents with celiac disease in a tertiary Brazilian referral center: a cross-sectional and retrospective study

CorrectionUnfortunately, after publication of this article [1], it was noticed that the names of the second and third authors were incorrectly displayed, respectively, as Glauce Hiromi Yonaminez and Carla Aline Satiro. The correct names are Glauce Hiromi Yonamine and Carla Aline Fernandes Satiro and can be seen in the corrected author list above. The original article has also been updated to correct this error.

Cow's milk allergy: Evaluating tolerance through skin-prick test.

Objective: To evaluate the wheal diameter in allergy skin-prick tests (SPT) with cows milk extract (CM) comparing tolerant and persistent patients. Method: A retrospective cohort study involving database analysis of children with diagnosis of cows milk protein allergy (CMPA) mediated by immunoglobulin E in a specialized outpatient clinic that regularly performed SPT between January 2000 and July 2015. Patients were allocated into two groups: tolerant or persistent. Comparisons were made at diagnosis and over time between tolerant and persistent patients using Fishers, Mann-Whitney or Wilcoxon tests and significance level at 5%. Results: After applying inclusion and exclusion criteria, the sample includes 44 patients (29 tolerant and 15 who persisted with CMPA). In the tolerant group, the medians of SPT were: 6 mm at diagnosis and 2 mm at the development of tolerance; a significant difference (p<0.0001) was found. In the persistent group, the median SPT at diagnosis was 7 mm, while in the last SPT it was 5 mm, with no statistical difference (p=0.173). The comparison of medians in the last SPT between groups was significant (p=0.001), with a reduction greater than 50% in SPT in the tolerant group. Conclusion: Serial SPTs were useful for diagnosis, and a decrease higher than 50% in diameter can indicate the moment to perform oral food challenge (OFC) tests, helping to detect tolerance in CMPA.

Difficulties of caregivers of cow's milk allergy patients in understanding the labeling of processed products

Methods Cross-sectional and descriptive study was carried out with CMA patient’s caregivers in follow-up at a pediatric reference center for FA. All of them were previously instructed about labels. This study included a questionnaire about the knowledge regarding the labels reading. Caregivers evaluated 20 labels (15 of foods, 3 of medicines and 2 of cosmetics) and should decide if the product was safe and the reason it can or not be offered to the patients. 15/20 contained words meaning milk protein. Results were expressed in number of labels reading (20 labels/caregivers)

Evaluating the role of clinical history and laboratorial tests in IgE mediated cow's milk allergy diagnosis

Background IgE mediated cow’s milk allergy (CMA) is a frequent disease in pediatric population, and challenge tests are considered gold standard in its diagnosis, although its use is limited in clinical practice. An appropriated anamnesis and laboratorial analysis are the most frequent and feasible used tools. The aim of this study was to evaluate the role of these practices in IgE mediated CMA diagnosis.

Tolerance to baked milk in Brazilian children with persistent cow’s milk allergy

Methods Patients with cow s milk allergy, over 4 years-old, were submitted to oral challenge with baked milk, from January to November, 2013, at Universidade de Sao Paulo, Brazil. The tested product was a muffin that contained 2,8 g milk protein and was baked at 350° F in an oven for 30 minutes. The challenge was made under physician supervision and at the first sign of allergy reaction it was discontinued, and the patient received the proper medical assistance.

Oral food desensitisation: are the patients safe after the end of protocol?

Desensitization protocols are increasing in food allergy centers and a higher number of patients submitted to these protocols have been showing a higher number of adverse events even after well succeed procedure. The aim of this study is to describe adverse reactions after cows milk desensitization.

182 Perceptions of Caregivers of Patients with Cow Milk Allergy Regarding the Treatment

Background To understand the perceptions of caregivers of patients with cow milk allergy (CMA) regarding the disease and its treatment. Methods Qualitative study in which caregivers of children and adolescents with confirmed CMA followed, at least, for 1 year, were interviewed. They were recruited from outpatient clinic of Allergy and Immunology Division from a tertiary pediatric hospital in São Paulo, Brazil. The interviews were conducted under conditions of privacy and 2 opened questions were proposed: “Tell me about your experience with cows milk allergy treatment” and “What do you expect from your childs disease treatment?” Data were audio-recorded, transcribed, analyzed using the content analysis method and categories and subcategories were generated based on their speeches. Results Nine interviews were done and 3 categories with subcategories emerged: A. Treatment and education of the patient and their caregivers (life experiences, bases of treatment, coping with the disease). B. Resolution of the disease (hope, gradual improvement). C. Quality of life (social inclusion, family daily activities, costs of dietary treatment). Caregivers experienced difficulties during the initial treatment but pointed out that the guidance given during follow-up made the adjustments easier. They also compared CMA with other chronic diseases and highlighted the importance of their children follow-up in this institution for adequate control. They commented on the difficulties about lack of cooperation from other family members regarding the restrictive diet, their experience coping with allergic reactions, doubts about the treatment and gaps on knowledge about the disease by other physicians and people. The majority of relatives was satisfied with the gradual improvement of patients, although there are no drugs or vaccines for treatment, and observed a reduction on the severity of symptoms and tolerance of milk traces. In addition, they commented on the efforts to give a normal life for their children, the changes in their daily lives and the difficulty to buy special products. Conclusions This qualitative study allowed us to understand how families cope with the disease, their histories and hopes about the treatment. They feel a great burden of the disease and need support and orientation from health professionals.