World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update – XII – Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA

Antonio Bognanni, MD, PhD (c); Alessandro Fiocchi, MD; Stefania Arasi, MD, MSc, PhD; Derek K. Chu, MD, PhD; Ignacio Ansotegui, MD, PhD; Amal H. Assa'ad, MD; Sami L. Bahna, MD, DrPH; Roberto Berni Canani, MD, PhD; Martin Bozzola, MD; Lamia Dahdah, MD; Christophe Dupont, MD, PhD; Piotr Dziechciarz, MD, PhD; Motohiro Ebisawa, MD, PhD; Ramon T. Firmino, MD; Alexandro Chu, BHSc(Hons); Elena Galli, MD, PhD; Andrea Horvath, MD, PhD; Rose Kamenwa, MD; Gideon Lack, MBBCh; Haiqi Li, MD; Alberto Martelli, MD; Anna Nowak-Węgrzyn, MD, PhD; Nikolaos G. Papadopoulos, MD, PhD; Ruby Pawankar, MD, PhD; Yetiani Roldan, MD; Maria Said, RN; Mario Sánchez-Borges, MD; Raanan Shamir, MD, PhD; Jonathan M. Spergel, MD, PhD; Hania Szajewska, MD; Luigi Terracciano, MD; Yvan Vandenplas, MD, PhD; Carina Venter, PhD, RD; Siw Waffenschmidt, PhD; Susan Waserman, MD, MSc; Amena Warner, RN, SN (PG Dip); Gary W.K. Wong, MD; Holger J. Schünemann, MD, MSc, PhD; Jan L. Brozek, MD, PhD

World Allergy Organization Journal (Apr 2024)

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update – XII – Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA

Antonio Bognanni, MD, PhD (c),
Alessandro Fiocchi, MD,
Stefania Arasi, MD, MSc, PhD,
Derek K. Chu, MD, PhD,
Ignacio Ansotegui, MD, PhD,
Amal H. Assa'ad, MD,
Sami L. Bahna, MD, DrPH,
Roberto Berni Canani, MD, PhD,
Martin Bozzola, MD,
Lamia Dahdah, MD,
Christophe Dupont, MD, PhD,
Piotr Dziechciarz, MD, PhD,
Motohiro Ebisawa, MD, PhD,
Ramon T. Firmino, MD,
Alexandro Chu, BHSc(Hons),
Elena Galli, MD, PhD,
Andrea Horvath, MD, PhD,
Rose Kamenwa, MD,
Gideon Lack, MBBCh,
Haiqi Li, MD,
Alberto Martelli, MD,
Anna Nowak-Węgrzyn, MD, PhD,
Nikolaos G. Papadopoulos, MD, PhD,
Ruby Pawankar, MD, PhD,
Yetiani Roldan, MD,
Maria Said, RN,
Mario Sánchez-Borges, MD,
Raanan Shamir, MD, PhD,
Jonathan M. Spergel, MD, PhD,
Hania Szajewska, MD,
Luigi Terracciano, MD,
Yvan Vandenplas, MD, PhD,
Carina Venter, PhD, RD,
Siw Waffenschmidt, PhD,
Susan Waserman, MD, MSc,
Amena Warner, RN, SN (PG Dip),
Gary W.K. Wong, MD,
Holger J. Schünemann, MD, MSc, PhD,
Jan L. Brozek, MD, PhD

Affiliations

Antonio Bognanni, MD, PhD (c): Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy
Alessandro Fiocchi, MD: Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy; Corresponding author
Stefania Arasi, MD, MSc, PhD: Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
Derek K. Chu, MD, PhD: Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
Ignacio Ansotegui, MD, PhD: Hospital Quironsalud Bizkaia, Bilbao-Erandio, Spain
Amal H. Assa'ad, MD: Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
Sami L. Bahna, MD, DrPH: Allergy and Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
Roberto Berni Canani, MD, PhD: Pediatric Allergy Program at the Department of Translational Medical Science, and ImmunoNutritionLab at Ceinge Advanced Biotechnologies, University of Naples Federico II, Naples, Italy
Martin Bozzola, MD: Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada; Department of Pediatrics, British Hospital-Perdriel, Buenos Aires, Argentina
Lamia Dahdah, MD: Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, Rome 00165, Italy
Christophe Dupont, MD, PhD: Paris Descartes University, Pediatric Gastroenterology, Necker Hospital, Paris, France; Clinique Marcel Sembat, Boulogne-Billancourt, France
Piotr Dziechciarz, MD, PhD: Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
Motohiro Ebisawa, MD, PhD: Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
Ramon T. Firmino, MD: Faculty of Medical Sciences of Campina Grande, UNIFACISA University Centre, Campina Grande, Paraiba, Brazil
Alexandro Chu, BHSc(Hons): Department of Medicine, Evidence in Allergy Group, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
Elena Galli, MD, PhD: Pediatric Allergy Unit, San Pietro Hospital - Fatebenefratelli, Rome, Italy
Andrea Horvath, MD, PhD: Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
Rose Kamenwa, MD: Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
Gideon Lack, MBBCh: King's College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Pediatric Allergy, St Thomas' Hospital, London, UK
Haiqi Li, MD: Department of Primary Child Care, Children's Hospital, Chongqing Medical University, China
Alberto Martelli, MD: Member of Italian Society of Allergy and Pediatric Immunology (SIAIP), Italy
Anna Nowak-Węgrzyn, MD, PhD: Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY, USA; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
Nikolaos G. Papadopoulos, MD, PhD: Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK; Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
Ruby Pawankar, MD, PhD: Division of Allergy, Department of Pediatrics, Nippon Medical School, Tokyo, Japan
Yetiani Roldan, MD: Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
Maria Said, RN: Allergy & Anaphylaxis Australia, Castle Hill, New South Wales, Australia
Mario Sánchez-Borges, MD: Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad and Clínica El Avila, Caracas, Venezuela
Raanan Shamir, MD, PhD: Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Jonathan M. Spergel, MD, PhD: Division of Allergy and Immunology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
Hania Szajewska, MD: Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
Luigi Terracciano, MD: Pediatric Primary Care, National Pediatric Health Care System, Milan, Italy
Yvan Vandenplas, MD, PhD: Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, Brussels, Belgium
Carina Venter, PhD, RD: Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
Siw Waffenschmidt, PhD: Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; Institute for Quality and Efficiency in Health Care, Cologne, Germany
Susan Waserman, MD, MSc: Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada
Amena Warner, RN, SN (PG Dip): Allergy UK, London, England, UK
Gary W.K. Wong, MD: Department of Paediatrics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
Holger J. Schünemann, MD, MSc, PhD: Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Medicine, Division of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
Jan L. Brozek, MD, PhD: Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Ontario, Canada

Journal volume & issue: Vol. 17, no. 4
p. 100888

Abstract

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Background: Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit. Objective: These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA. Methods: WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders. Results: After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.The issued recommendations are labeled as “conditional” following the GRADE approach due to the very low certainty about the health effects based on the available evidence. Conclusions: If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers’ values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.

Published in World Allergy Organization Journal

ISSN: 1939-4551 (Online)
Publisher: Elsevier
Country of publisher: Netherlands
LCC subjects: Medicine: Internal medicine: Specialties of internal medicine: Immunologic diseases. Allergy
Website: https://www.sciencedirect.com/journal/world-allergy-organization-journal

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