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Delphi, Consensus, Cow’s milk allergy CMPA, CMPA prevention, CMPA diagnosis, CMPA treatment, CMPA progression, OIT
Background: The present study explores the professional opinion of a wide range of experts from the Iberian Peninsula (Spain and Portugal) and their degree of consensus about CMPA’s prevention, diagnosis, treatment and progression.
Material and methods: A 57-item survey divided in four blocks: Prevention (14 items), Diagnosis (10 items), Treatment (19 items) and Progression (14 items) was completed by 160 panellists, experts in CPMA management (116 Spain, 44 Portugal). Each one answered the questionnaire, formulated in Portuguese and Spanish, by individually accessing an online platform in two consecutive rounds. Five possible answers were possible: ‘‘completely agree’’, ‘‘agree’’, ‘‘neither agree nor disagree’’, ‘‘disagree’’ and ‘‘completely disagree’’. A modified Delphi method was used.
Results: Consensus (more than 66% agree) was reached in 39 items (68.4%) and Discrepancy (less than 50% agree) in nine items (15.7%). Block-separated analysis offers valuable differences regarding consensus. The Prevention block only reached 50%; the Diagnosis block 90%; the Treatment block 73.68%, showing a high degree of agreement on dietary treatment (15/16 items), and discrepancy or less agreement on immunotherapy treatments. The Progression block reached 71.4% consensus with discrepancy with regard to the time to perform oral food challenge and negatives prognosis consequences of accidental milk ingestion.
Conclusions: This study displays the current opinions of a wide group of experts on CMPA from the Iberian Peninsula and evidence discussion lines in CMPA management. The questions on which there were situations of discrepancy, provide us with very useful information for promoting new, rigorous research enabling us to draw conclusions on these controversial aspects.
2. Garcia Ara MC, Boyado MT, Diaz Pena JM, Martin Munoz ˜ F, Pascual C, Garcia Sanchez G, et al. Incidencia de alergia a leche de vaca y su repercusión en el consumo de hidrolizados. An Pediatr. 2003;58:100-5.
3. Fiocchi A, Schünemann HJ, Brozek J, Restani P, Beyer K, Troncone R, et al. Diagnosis and rationale for action against cow’s milk allergy (DRACMA): a summary report. J Allergy Clin Immunol. 2010;126:1119-28.e12.
4. Terracciano L, Schünemann H, Brozek J, Agostoni C, Fiocchi A. DRACMA Implementation Committee, World Allergy Organisation. How DRACMA changes clinical decision for the individual patient in CMA therapy. Curr Opin Allergy Clin Immunol. 2012;12:316-22.
5. Muraro A, Halken S, Arshad SH, Beyer K, Dubois AE, Du Toit G, et al. EAACI Food Allergy and Anaphylaxis Guidelines Group. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy. 2014;69:590-601.
6. Martorell-Aragonés A, Echeverría-Zudaire L, Alonso-Lebrero E, Boné-Calvo J, Martín-Munoz ˜ MF, Nevot-Falcó S, et al. Food allergy committee of SEICAP (Spanish Society of Pediatric Allergy, Asthma and Clinical Immunology). Position document: IgE-mediated cow’s milk allergy. Allergol Immunopathol (Madr). 2015;43:507-26.
7. Koletzko S, Niggemann B, Arato A, Dias JA, Heuschkel R, Husby S, et al. European Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr. 2012;55:221-9.
8. Vandenplas Y, Koletzko S, Isolauri E, Hill D, Oranje AP, Brueton M, et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child. 2007;92:902-8.
9. Luyt D, Krishnan MT, Huber P, Clark A. Practice of the treatment of milk allergy in the UK: a national audit. Int Arch Allergy Immunol. 2016;169:62-8.
10. The RAND/UCLA Appropriateness Method User’s Manual | RAND [Internet]. Available from: http://www.rand.org/pubs/monograph reports/MR1269.html [cited 16.1.13].
11. Høst A, Koletzko B, Dreborg S, Muraro A, Wahn U, Aggett P, et al. Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child. 1999;81: 80-4.
12. Greer FR, Sicherer SH, Burks AW. American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology, Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121:183-91.
13. Alonso Lebrero A. Prevención de la alergia alimentaria: una revisión crítica. Allergo Immunopathol. 2011;39:22-6.
14. Van Odijk J, Kull I, Borres MP, Brandtzaeg P, Edberg U, Hanson LA, et al. Breastfeeding and allergic disease: a multidisciplinary review of the literature (1966-2001) on the mode of early feeding in infancy and its impact on later atopic manifestations. Allergy. 2003;58:833-43.
15. Yang YW, Tsai CL, Lu CY. Exclusive breastfeeding and incident atopic dermatitis in childhood: a systematic review and meta-analysis of prospective cohort studies. Br J Dermatol. 2009;161:373-83.
16. Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, Aalberse R, et al. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol. 2004;15:291-307.
17. Wright AL, Holberg CJ, Taussig LM, Martinez FD. Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood. Thorax. 2001;56:192-7.
18. Elliott L, Henderson J, Northstone K, Chiu GY, Dunson D, London SJ. Prospective study of breast-feeding in relation to wheeze, atopy, and bronchial hyperresponsiveness in the Avon Longitudinal Study of Parents and Children (ALSPAC). J Allergy Clin Immunol. 2008;122:49-54.e1-3.
19. Sears MR, Greene JM, Willan AR, Taylor DR, Flannery EM, Cowan JO, et al. Long-term relation between breastfeeding and development of atopy and asthma in children and young adults: a longitudinal study. Lancet. 2002;360:901-7.
20. Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and childhood asthma: systematic review and meta-analysis. Am J Epidemiol. 2014;179:1153-67.
21. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev. 2012;9:CD000133.
22. Barrio J, Díaz-Martín JJ, Manrique I, Martín Martínez B, Ortega E. Consenso experto sobre los aspectos nutricionales de las leches infantiles de inicio y continuación. An Pediatr (Barc). 2015;83:376-86.
23. von Berg A, Koletzko S, Grübl A, Filipiak-Pittroff B, Wichmann HE, Bauer CP, et al. The effect of hydrolyzed cow’s milk formula for allergy prevention in the first year of life: the German Infant Nutritional Intervention Study, a randomized double-blind trial. J Allergy Clin Immunol. 2003;111:533-40.
24. Osborn DA, Sinn JK. Prebiotics in infants for prevention of allergy. Cochrane Database Syst Rev. 2013:CD006474.
25. Martorell A, Plaza AM, Boné J, Nevot S, García Ara MC, Echeverria L, et al. Cow’s milk protein allergy. A multicenter study: clinical and epidemiological aspects. Allergol Immunopathol. 2006;34:46-53.
26. Katz Y, Rajuan N, Goldberg MR, Eisenberg E, Heyman E, Cohen A, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126:e1.77-82.
27. Geenhawt M, Fleischer D, Spergels J. It time for a randomized trial on early introduction of milk? J Allergy Clin Immunol Pract. 2016;4:489-90.
28. Martorell-Aragonés A, Echeverría-Zudaire L, Alonso-Lebrero E, Boné-Calvo J, Martín-Munoz ˜ MF, Nevot-Falcó S, et al. Position document: IgE-mediated cow’s milk allergy. Allergol Immunopathol (Madr). 2015;43:507-26.
29. García-Ara C, Boyano-Martínez T, Díaz-Pena JM, Martín-Munoz ˜ F, Reche-Frutos M, Martín-Esteban M. Specific IgE levels in the diagnosis of immediate hypersensitivity to cows’ milk protein in the infant. J Allergy Clin Immunol. 2001;107:185-90.
30. Soares-Weiser K, Takwoingi Y, Panesar SS, Muraro A, Werfel T, Hoffmann-Sommergruber K, et al. The diagnosis of food allergy: a systematic review and meta-analysis. Allergy. 2014;69:76-86.
31. Niggemann B, Reibel S, Wahn U. The atopy patch test (APT) - a useful tool for the diagnosis of food allergy in children with atopic dermatitis. Allergy. 2000;55:281-5.
32. Martorell Aragonés A. Implicación etiológica de los alimentos en la dermatitis atópica: datos en contra. Allergol Immunopathol (Madr). 2002;30:120-6.
33. Barbi E, Gerarduzzi T, Longo G, Ventura A. Fatal allergy as a possible consequence of long-term elimination diet. Allergy. 2004;59:668-9.
34. Martorell A, De la Hoz B, Ibánez ˜ MD, Bone J, Terrados MS, Michavila A, et al. Oral desensitization as a useful treatment in 2-year-old children with cow’s milk allergy. Clin Exp Allergy. 2011;41:1297-304.
35. García-Ara MC, Boyano-Martínez MT, Díaz-Pena JM, MartínMunoz ˜ MF, Martín-Esteban M. Cow’s milk-specific immunoglobulin E levels as predictors of clinical reactivity in the follow-up of the cow’s milk allergy infants. Clin Exp Allergy. 2004;34:866-70.
36. Martorell A, García Ara MC, Plaza AM, Boné J, Nevot S, Echeverria L, et al. The predictive value of specific immunoglobulin E levels in serum for the outcome of the development of tolerance in cow’s milk allergy. Allergol Immunopathol (Madr). 2008;36:325-30.
37. Allen CW, Kemp AS, Campbell DE. Dietary advice, dietary adherence and the acquisition of tolerance in egg-allergic children: a 5-yr follow-up. Pediatr Allergy Immunol. 2009;20: 213-8.
38. Kim JS, Sicherer S. Should avoidance of foods be strict in prevention and treatment of food allergy? Curr Opin Allergy Clin Immunol. 2010;10:252-7.
39. DunnGalvin A, Daly D, Cullinane C, Stenke E, Keeton D, Erlewyn-Lajeunesse M, et al. Highly accurate prediction of food challenge outcome using routinely available clinical data. J Allergy Clin Immunol. 2011;127:633-9.