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Prevention and treatment of cow's milk allergy
  1. E RIVA,
  3. L FIORI,
  1. Department of Paediatrics
  2. University of Milan Medical School
  3. San Paolo Biomedical Institute
  4. Via Di Ridini 8
  5. 20142 Milan, Italy

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Editor,—Divergences in existing guidelines on the prevention and treatment of cow's milk allergy (CMA) in infants1-3 seemed settled when a joint statement by the committees of ESPACI/ESPGHAN appeared inADC. 4 However, we take exception to some of the assumptions, which have been left open to challenge from both nutritional and allergological points of view. Our concern is that lactose free diets from birth may cause neurological problems in healthy children. Galactose is a functionally important component of myelin galactolipids, but it is unclear whether a lactose free diet plays a role in the clinical neurological abnormalities of children with galactosaemia. However, lactose is essential for patients with UDP-galactose-4-epimerase deficiency.5 Though rare, this disorder should be considered in the evaluation of the risk:benefit ratio and the costs of planning a prevention strategy for which the benefits are still unclear. In this context, issues of colonic ecology and malabsorption take second place.4 The use of screening tests for errors of lactose metabolism as interpreted in the statement may also be misleading. The claim that “feeding lactose-free diets from birth . . . will cause false negative results in most neonatal screening tests for galactosaemia” overlooks the fact that these tests do not establish blood galactose levels but the presence/deficiency of the enzymes responsible for galactosaemia.5 The assertion that “. . . formulas based on intact soy protein isolates are not recommended for the initial treatment of food allergy in infants, although a proportion of infants with cow's milk protein allergy tolerate soy formula” is based on the ESPGAN Committee on nutrition3 and on the AAP recommendations.6 While the former concerns itself with clinical gastrointestinal manifestations, the latter recommendations state in conclusion (point 8): “Most infants with documented IgE-mediated allergy to cow milk protein will do well on isolated soy protein-based formula”. Initial treatment for allergic disease is avoidance of the incriminated allergen. Soy formula has been recommended in treatment of CMA on grounds of efficacy, adequate nutrient intake, and cost.2 ,7 In the absence of prospective studies comparing the allergenicity of cow's milk hydrolisates against soy formulas in children with CMA, the rationale to alter this indication appears to be lacking.