Allergies

In case of food intolerance (e.g. enzyme deficiency), the immune system is not (or almost not) involved in the reactions. “Allergy to lactose” is therefore an improper wording, adverse reaction to lactose (diarrhea, etc.) should be named “lactose intolerance”.

Lactose intolerance is due to the absence or a metabolic deficiency of the lactase enzyme (disaccharidase of the intestinal brush border). If not hydrolyzed, lactose cannot be absorbed in the intestine. Therefore, the bacterial flora transforms this disaccharide, through a fermentation process, in short chain organic acids and gas. This fermentation can lead to abdominal pain, flatus, bloating, loose stools or watery diarrhea. To manage lactose intolerance, lactose should be avoided in the diet¹.

So, for infants who are suffering from a lactose intolerance, it is recommended to feed them with a lactose free formula, and as such a rice-based formula can also be used in the management of lactose intolerance.

¹ Heine R.G., et al., Lactose intolerance and gastrointestinal cow’s milk allergy in infants and children –common misconceptions revisited . World Allergy Organization Journal 10:41 DOI (2017).

Allergies are the expression of an adverse reaction of the organism that does not tolerate foreign elements (food elements, dust, insect bites...). Food allergy is defined as an immunologic reaction to a harmless substance in food. This type of reaction is called an allergic reaction. There are several types of immunologic reactions depending on whether it implies Immunoglobulin E (IgE) or not. IgE-mediated reactions occur usually a few minutes or a few hours after the ingestion of the allergen whereas non IgE-mediated reaction can take place a few days after¹.

Classification of adverse reactions to food (issued from²)

Allergy may lead to several symtoms ^1-4

¹ Luyt D., et al. BSACI guideline for the diagnosis and management of cow's milk allergy. Clin Exp Allergy. 44(5):642-72 (2014). 
² Scientific Opinion on the evaluation of allergenic foods and food ingredients for labelling purposes. EFSA Journal 12, 3894 (2014). 
³ Fiocchi A., et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol  Suppl 21, 1–125 (2010). 
⁴ Koletzko S., et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J. Pediatr. Gastroenterol. Nutr. 55, 221–229 (2012).

Several studies indicate that 75 % of allergic reactions among children are due to a limited number of foods, namely egg, peanut, cow’s milk, fish and various nuts¹.

There is evidence that the prevalence of food allergy has been increasing in recent decades, particularly in westernised countries².

On which data rely to see that food allergy prevalence has increased?

The best would be to rely on data provided by oral food challenge procedure, but conducting food challenges in large populations induces high costs and includes potential risks.

Therefore, data showing an increase in food allergy prevalence mainly comes from changes in hospital anaphylaxis admission rates derived from national government databases in westernised countries.
 

For example, the food anaphylaxis admission rates per 100,000 population per year rose:

• from 1.2 to 2.4 between 1998 and 2012 in the United Kingdom³
   
• from 5.6 in 2005-2006 to 8.2 in 2011-2012 (a 1.5-fold increase over 7 years) in Australia⁴; the highest rates occurred in children aged from 0 to 4 years, 21.7 in 2005-2006 and 30.3 in 2011-2012, a 1.4-fold increase.

¹Scientific Opinion on the evaluation of allergenic foods and food ingredients for labelling purposes. EFSA Journal 12, 3894 (2014).
² Tang M. L. K. & Mullins R. J. Food allergy: is prevalence increasing? Intern Med J 47, 256–261 (2017).
³ Turner P. J. et al. Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012. J. Allergy Clin. Immunol. 135, 956-963.e1 (2015).
⁴ Mullins R. J., Dear K. B. G. & Tang M. L. K. Time trends in Australian hospital anaphylaxis admissions in 1998-1999 to 2011-2012. J. Allergy Clin. Immunol. 136, 367–375 (2015).

¹ Vandenplas Y., et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch. Dis. Child. 92, 902–908 (2007).
² Fiocchi A., et al. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol Suppl 21, 1–125 (2010).
³ Saarinen K. M., Pelkonen A. S., Mäkelä M. J. & Savilahti E. Clinical course and prognosis of cow’s milk allergy are dependent on milk-specific IgE status. J. Allergy Clin. Immunol. 116, 869–875 (2005).
⁴ Luyt D., et al. BSACI Guideline for the diagnosis and management of cow’s milk allergy. Clin. Exp. Allergy 44, 642–672 (2014).
⁵ Koletzko S., et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. Journal Pediatrics of Gastroenteroly and Nutrition 55, 221–229 (2012). 

Regurgitations are frequent in the first year of life. They can be due to an immaturity of the lower esophageal sphincter or can be a symptom of CMA. In case of regurgitations and suspicion of CMA, a thickened CMA formula is an adapted response¹ (see the algorithm thereafter, adapted from¹).

Algorithms for Common Gastrointestinal Disorders¹ 

*CoMiSS^TM: The Cow's Milk-related Symptom Score is an awareness tool to recognize possible manifestations of CMA². The cut-off value of ≥12 has been selected as the criterion to pick up infants at risk of CMA². It is currently under validation^3–5. CoMiSS^TM is a trademark of Société des Produits Nestlé S.A., Vevey, Switzerland.

AR-formula: anti-regurgitation formula 
BF: breastfed 
FF: formula fed 
eHF: extensively hydrolysed formula 
GERD: gastroesophageal reflux disease

¹ Vandenplas Y. Algorithms for Common Gastrointestinal Disorders. J. Pediatr. Gastroenterol. Nutr. 63 Suppl 1, S38-40 (2016).
² Vandenplas Y., et al. A workshop report on the development of the Cow’s Milk-related Symptom Score awareness tool for young children. Acta Paediatr. 104, 334–339 (2015).
³ Prasad R., Venkata R. S. A., Ghokale P., Chakravarty P. & Anwar F. Cow’s Milk-related Symptom Score as a predictive tool for cow’s milk allergy in Indian children aged 0-24 months. Asia Pac Allergy 8, e36 (2018).
⁴ Vandenplas Y., et al. The Cow Milk Symptom Score (CoMiSS^TM) in presumed healthy infants. PLoS ONE 13, e0200603 (2018).
⁵ Vandenplas Y., Steenhout P., Järvi A., Garreau A-S. & Mukherjee, R. Pooled Analysis of the Cow’s Milk-related-Symptom-Score (CoMiSS^TM) as a Predictor for Cow’s Milk Related Symptoms. Pediatr Gastroenterol Hepatol Nutr 20, 22–26 (2017).

¹ American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 106: 346-349 (2000).