Munblit Daniel, Perkin Michael R, Palmer Debra J, Allen Katie J, Boyle Robert J
National Heart and Lung Institute, Imperial College London, London, England.
Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child Health, Sechenov First Moscow State Medical University, Moscow, Russia.
JAMA Pediatr. 2020 Jun 1;174(6):599-608. doi: 10.1001/jamapediatrics.2020.0153.
Sales of specialized formula for managing cow's milk allergy (CMA) have increased, triggering concern that attribution of common infant symptoms, such as crying, vomiting, and rashes, to CMA may be leading to overdiagnosis, which could undermine breastfeeding.
To understand whether CMA guideline recommendations might promote CMA overdiagnosis or undermine breastfeeding.
We reviewed recommendations made in CMA guidelines and critically appraised 2 key recommendations. First, we reviewed relevant literature summarizing whether maternal or infant dietary exclusion of cow's milk is effective for managing common infant symptoms. Second, we reviewed published data on breastmilk composition and thresholds of reactivity in CMA to estimate the probability that cow's milk protein in human breastmilk can trigger symptoms in infants with CMA. We also documented the level of commercial involvement in CMA guidelines.
We reviewed 9 CMA guidelines published from 2012 to 2019. Seven suggest considering CMA as a cause of common infant symptoms. Seven recommend strict maternal cow's milk exclusion for managing common symptoms in breastfed infants. We found CMA proven by food challenge affects approximately 1% of infants, while troublesome crying, vomiting, or rashes are each reported in 15% to 20% of infants. We found clinical trials do not provide consistent support for using maternal or infant cow's milk exclusion to manage common symptoms in infants without proven CMA. We estimated that for more than 99% infants with proven CMA, the breastmilk of a cow's milk-consuming woman contains insufficient milk allergen to trigger an allergic reaction. Three CMA guidelines were directly supported by formula manufacturers or marketing consultants, and 81% of all guideline authors reported a conflict of interest with formula manufacturers.
Recommendations to manage common infant symptoms as CMA are not evidence based, especially in breastfed infants who are not directly consuming cow's milk. Such recommendations may cause harm by undermining confidence in breastfeeding.
用于管理牛奶蛋白过敏（CMA）的特殊配方奶粉销量增加，引发了人们对将常见婴儿症状（如哭闹、呕吐和皮疹）归因于CMA可能导致过度诊断的担忧，这可能会损害母乳喂养。
了解CMA指南建议是否可能促进CMA的过度诊断或损害母乳喂养。
我们审查了CMA指南中的建议，并对两项关键建议进行了批判性评估。首先，我们回顾了相关文献，总结了母亲或婴儿饮食中排除牛奶对管理常见婴儿症状是否有效。其次，我们审查了已发表的关于母乳成分和CMA中反应阈值的数据，以估计人乳中的牛奶蛋白引发CMA婴儿症状的可能性。我们还记录了商业机构对CMA指南的参与程度。
我们审查了2012年至2019年发表的9项CMA指南。其中7项建议将CMA视为常见婴儿症状的一个原因。7项建议母亲严格排除牛奶以管理母乳喂养婴儿的常见症状。我们发现经食物激发试验证实的CMA约影响1%的婴儿，而约15%至20%的婴儿报告有烦人的哭闹、呕吐或皮疹症状。我们发现临床试验并未一致支持使用母亲或婴儿排除牛奶来管理未证实患有CMA的婴儿的常见症状。我们估计，对于超过99%经证实患有CMA的婴儿，食用牛奶的女性的母乳中所含的牛奶过敏原不足以引发过敏反应。3项CMA指南得到了配方奶粉制造商或营销顾问的直接支持，所有指南作者中有81%报告与配方奶粉制造商存在利益冲突。
将常见婴儿症状作为CMA进行管理的建议缺乏循证依据，尤其是在未直接食用牛奶的母乳喂养婴儿中。此类建议可能会因削弱对母乳喂养的信心而造成危害。
