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1. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update – XVI - Nutritional management of cow's milk allergy

Author

Carina Venter, Rosan Meyer, Marion Groetch, Anna Nowak-Wegrzyn, Maurizio Mennini, Ruby Pawankar, Rose Kamenwa, Amal Assa'ad, Shriya Amara, Alessandro Fiocchi, Antonio Bognanni, Ignacio Ansotegui, Stefania Arasi, Sami L. Bahna, Roberto Berni Canani, Martin Bozzola, Jan Brozek, Derek Chu, Lamia Dahdah, Christophe Dupont, Motohiro Ebisawa, Ramon T. Firmino, Elena Galli, Gideon Lack, Haiqi Li, Alberto Martelli, Nikolas G. Papadopoulos, Maria Said, Mario Sánchez-Borges, Holger Schunemann, Raanan Shamir, Jonathan Spergel, Hania Szajewska, Luigi Terracciano, Yvan Vandenplas, Susan Waserman, Amena Warner, and Gary W.K. Wong

Subjects
Cow's milk allergy, Nutrition, Baked milk, Hypoallergenic formulas, Plant based alternatives, Immunologic diseases. Allergy, RC581-607
Abstract

Cow's milk allergy (CMA) is one of the most common presentations of food allergy in early childhood. Management of CMA involves individualized avoidance of cow's milk and other mammalian milk and foods containing these. Optimal elimination of cow's milk avoidance includes: label reading; information about safe and nutritious substitute foods; appropriate choice of infant formula or a plant-based food; establishing tolerance to baked milk and monitoring nutritional intake and growth. Substitute formulas are divided into soy formula (not hydrolyzed), milk-based extensively hydrolyzed formulas, rice based extensive, and partially hydrolyzed formulas and amino acid-based formulas. The use of other mammalian milks is not recommended for the management of cow's milk allergy due to a high level of cross-reactivity and nutritional concerns. For toddlers who are eating well, children, and adults, a suitable plant-based beverage may be a suitable alternative to a specialized formula, following careful nutritional considerations. Families need to be instructed on finding suitable nutritious foods and how to prepare suitable meals at home. Individuals with CMA also need to know how to identify and treat acute severe reactions.

Published
2024
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2. 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

Author

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, and Jan L. Brozek, MD, PhD

Subjects
Milk allergy, Milk replacement formulas, Probiotics, Clinical practice guidelines, GRADE, Immunologic diseases. Allergy, RC581-607
Abstract

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
2024
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3. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update – X – Breastfeeding a baby with cow's milk allergy

Author

Vicki McWilliam, PhD, AdvAPD, Merryn J. Netting, PhD, BSc, BND, Evelyn Volders, PhD, AdvAPD, Debra J. Palmer, PhD, BSc, BND, Ignacio Ansotegui, Stefania Arasi, Amal H. Assa'ad, Sami L. Bahna, Roberto Berni Canani, Antonio Bognanni, Martin Bozzola, Jan Brozek, Derek Chu, Lamia Dahdah, Christophe Dupont, Piotr Dziechciarz, Motohiro Ebisawa, Ramon T. Firmino, Alessandro Fiocchi, Elena Galli, Rose Kamenwa, Gideon Lack, Haiqi Li, Alberto Martelli, Anna Nowak-Węgrzyn, Nikolas G. Papadopoulos, Ruby Pawankar, Maria Said, Mario Sánchez-Borges, Holger Schunemann, Raanan Shamir, Jonathan Spergel, Hania Szajewska, Luigi Terracciano, Yvan Vandenplas, Susan Waserman, Carina Venter, Amena Warner, and Gary W.K. Wong

Subjects
Breastfeeding, Infant, IgE-mediated cow's milk allergy, Non-IgE-mediated cow's milk allergy, Maternal nutrition, Immunologic diseases. Allergy, RC581-607
Abstract

Cow's milk allergy is rare in exclusively breastfed infants. To support the continuation of breastfeeding an infant after diagnosis with a cow's milk allergy, it is critical to examine the evidence for and against any form of cow's milk elimination diet for lactating mothers. In this narrative review, we highlight the lack of high-quality evidence, hence subsequent controversy, regarding whether the minuscule quantities of cow's milk proteins detectable in human milk cause infant cow's milk allergy symptoms. Current clinical practice recommendations advise a 2–4 week trial of maternal cow's milk dietary elimination for: a) IgE-mediated cow's milk allergy only if the infant is symptomatic on breastfeeding alone; b) non-IgE-mediated associated symptoms only if the history and examination strongly suggest cow's milk allergy; and c) infants with moderate to severe eczema/atopic dermatitis, unresponsive to topical steroids and sensitized to cow's milk protein. There should be a clear plan for home reintroduction of cow's milk into the maternal diet for a period of 1 week to determine that the cow's milk elimination is responsible for resolution of symptoms, and then subsequent reoccurrence of infant symptoms upon maternal cow's milk reintroduction. The evidence base to support the use of maternal cow's milk avoidance for the treatment of a breastfed infant with cow's milk allergy is of limited strength due to a lack of high-quality, adequately powered, randomised controlled trials. It is important to consider the consequences of maternal cow's milk avoidance on reducing immune enhancing factors in breast milk, as well as the potential nutritional and quality of life impacts on the mother. Referral to a dietitian is advised for dietary education, along with calcium and vitamin D supplementation according to local recommendations, and a maternal substitute milk should be advised. However, for most breastfed infants with cow's milk allergy maternal cow's milk dietary elimination will not be required, and active support of the mother to continue breastfeeding is essential.

Published
2023
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4. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update – XIII – Oral immunotherapy for CMA – Systematic review

Author

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

Subjects
Milk allergy, Oral immunotherapy, Systematic review, Meta-analysis, GRADE, Immunologic diseases. Allergy, RC581-607
Abstract

Background: Allergy to cow's milk is the most common food allergy in infants and it is usually outgrown by 5 years of age. In some individuals it persists beyond early childhood. Oral immunotherapy (OIT, oral desensitization, specific oral tolerance induction) has been proposed as a promising therapeutic strategy for persistent IgE-mediated cow's milk allergy. We previously published the systematic review of OIT for cow's milk allergy (CMA) in 2010 as part of the World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. Objective: To systematically synthesize the currently available evidence about OIT for IgE-mediated CMA and to inform the updated 2022 WAO guidelines. Methods: We searched the electronic databases including PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the websites of selected allergy organizations. We included all studies irrespective of the language of the original publication. The last search was conducted in February 2021. We registered the protocol on Open Science Framework (10.17605/OSF.IO/AH2DT). Results: We identified 2147 unique records published between 2010 and 2021, including 13 randomized trials and 109 observational studies addressing cow's milk OIT. We found low-certainty evidence that OIT with unheated cow's milk, compared to elimination diet alone, increased the likelihood of being able to consume ≥150 ml of cow's milk in controlled settings (risk ratio (RR): 12.3, 95% CI: 5.9 to 26.0; risk difference (RD): 25 more per 100, 95% CI 11 to 56) as well as accidently ingest a small amount (≥5 ml) of cow's milk (RR: 8.7, 95% CI: 4.7 to 16.1; RD: 25 more per 100, 95% CI 12 to 50). However, 2–8 weeks after discontinuation of a successful OIT, tolerance of cow's milk persisted in only 36% (range: 20%–91%) of patients. OIT increased the frequency of anaphylaxis (rate ratio: 60.0, 95% CI 15 to 244; rate difference 5 more anaphylactic reactions per 1 person per year, 95% CI: 4 to 6; moderate evidence) and the frequency of epinephrine use (rate ratio: 35.2, 95% CI: 9 to 136.5; rate difference 268 more events per 100 person-years, 95% CI: 203 to 333; high certainty). OIT also increased the risk of gastrointestinal symptoms (RR 6.9, 95% CI 1.6–30.9; RD 28 more per 100, CI 3 to 100) and respiratory symptoms (RR 49.0, 95% CI 3.12–770.6; RD 77 more per 100, CI 62 to 92), compared with avoidance diet alone. Single-arm observational studies showed that on average 6.9% of OIT patients (95% CI: 3.8%–10%) developed eosinophilic esophagitis (very low certainty evidence). We found 1 trial and 2 small case series of OIT with baked milk. Conclusions: Moderate certainty evidence shows that OIT with unheated cow's milk in patients with IgE-mediated CMA is associated with an increased probability of being able to drink milk and, at the same time, an increased risk of serious adverse effects.

Published
2022
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5. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) Guideline update – XIV – Recommendations on CMA immunotherapy

Author

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

Subjects
Milk allergy, Immunotherapy, Practice guidelines, GRADE, Immunologic diseases. Allergy, RC581-607
Abstract

Background: The prevalence of cow's milk allergy (CMA) is approximately 2–4.5% in infants and less than 0.5% in adults. Most children outgrow cow's milk allergy in early childhood, particularly that to the baked milk products. Immunotherapy with unheated cow's milk has been used as a treatment option for those who have not yet outgrown CMA, but the benefits must be balanced with the adverse effects. Objective: These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of oral and epicutaneous immunotherapy for the treatment of IgE-mediated 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 public comment. Results: After a careful review of the summarized evidence and thorough discussions the WAO guideline panel suggests: a) using oral immunotherapy with unheated cow's milk in those individuals with confirmed IgE-mediated CMA who value the ability to consume controlled quantities of milk more than avoiding the large adverse effects of therapy, b) not using oral immunotherapy with unheated cow's milk in those who value avoiding large adverse effects of therapy more than the ability to consume controlled quantities of milk, c) using omalizumab in those starting oral immunotherapy with unheated cow's milk, d) not using oral immunotherapy with baked cow's milk in those who do not tolerate both unheated and baked milk, and e) not using epicutaneous immunotherapy outside of a research setting. The recommendations are labeled “conditional” due to the low certainty about the health effects based on the available evidence. Conclusions: Clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable effects of oral immunotherapy for IgE-mediated CMA and integrate them with the patients' values and preferences before deciding on a treatment option. More robust research is needed to determine with greater certainty which interventions are likely to be the most beneficial with the least harms, and to develop safer, low-cost, and equitable treatments.

Published
2022
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6. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines update – I – Plan and definitions

Author

Alessandro Fiocchi, MD, Antonio Bognanni, MD, Jan Brożek, MD, PhD, Motohiro Ebisawa, MD, PhD, Holger Schünemann, MD, Ignacio J. Ansotegui, MD, PhD, Stefania Arasi, MD, Amal H. Assa'ad, MD, Sami L. Bahna, MD, DrPH, Roberto Berni Canani, MD, PhD, Martin Bozzola, MD, Derek Chu, Lamia Dahdah, MD, Christophe Dupont, MD, PhD, Ramon Targino Firmino, Elena Galli, MD, PhD, Rose Kamenwa, MD, Gideon Lack, MD, Haiqi Li, MD, Alberto Martelli, MD, Anna Nowak-Węgrzyn, MD, Nikolas G. Papadopoulos, MD, PhD, Ruby Pawankar, MD, PhD, Maria Said, RN, Mario Sánchez-Borges, Raanan Shamir, PhD, Jonathan M. Spergel, MD, PhD, Hania Szajewska, MD, Luigi Terracciano, MD, Yvan Vandenplas, MD, PhD, Carina Venter, PhD, RD, Amena Warner, Susan Waserman, MD, MSc, and Gary W.K. Wong, MD

Subjects
Food allergy, Cow's milk allergy, Oral immunotherapy, GRADE, Immunologic diseases. Allergy, RC581-607
Abstract

Since the World Allergy Organization (WAO) Diagnosis and Rationale against Cow's Milk Allergy (DRACMA) Guidelines were published 10 years ago, new evidence has accumulated about the diagnosis, therapy, and specific immunotherapy for cow's milk allergy (CMA). For this reason, WAO has felt the need to update the guidelines.We introduce here this update. The new DRACMA guidelines aim to comprehensively address the guidance on diagnosis and therapy of both IgE non-IgE-mediated forms of cow's milk allergy in children and adults. They will be divided into 18 chapters, each of which will be dedicated to an aspect. The focus will be on the meta-analyzes and recommendations that will be expressed for the 3 most relevant clinical aspects: (a) the diagnostic identification of the condition; (b) the choice of the replacement formula in case of CMA in infancy when the mother is not able to breastfeed, and (c) the use of specific immunotherapy for cow's milk protein allergy.

Published
2022
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7. Pre-albumin as a marker for predicting weight loss in hospitalised children

Author

Del-Rossi Sean Quadros, Rose Kamenwa, Samuel Akech, and William Macharia

Subjects
hospital malnutrition, weight loss, serum pre-albumin, Nutrition. Foods and food supply, TX341-641, Nutritional diseases. Deficiency diseases, RC620-627
Abstract

Objectives: This study sought to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Design: A hospital-based longitudinal survey was carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: A total of 170 children aged 29 days to 15 years who met the inclusion criteria were included in the study. Outcome measures: Serum pre-albumin levels and weight were measured at admission and repeated after 48–96 h. Sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Results: Of the 170 children studied, 57% and 60% had a drop in serum pre-albumin level and weight within the first four days of hospitalisation respectively. A drop in pre-albumin occurred in 68% of the 103 patients who had weight loss (p < 0.001). Using a serum pre-albumin cut off point of < 0.15 g/l at admission, sensitivity and specificity of serum pre-albumin in predicting weight loss were 76.7% and 29.0% (negative predictive value = 42.9%; positive predictive value = 64.2%). Positive and negative likelihood ratios were low at 1.08 and 0.8. The majority of the patients (72.3%) were already at risk of malnutrition as determined by the pre-albumin risk stratification on admission. Conclusion: Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation. It is, however, useful in identifying patients at risk of malnutrition on admission and during hospitalisation.

Published
2019
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8. Hospital-acquired malnutrition in children at a tertiary care hospital

Author

Del-Rossi Sean Quadros, Rose Kamenwa, Samuel Akech, and William M Macharia

Subjects
anthropometric measurements, body mass index z-scores, hospital-acquired malnutrition, weight-for-height z-scores, Nutrition. Foods and food supply, TX341-641, Nutritional diseases. Deficiency diseases, RC620-627
Abstract

Objectives: This study sought to investigate the incidence and factors associated with hospital-acquired malnutrition in children. Design: A hospital-based longitudinal survey carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: One hundred and seventy children who met the inclusion criteria were included in the study. Outcome measures: Anthropometry was done at admission and discharge. Incidence of hospital-acquired malnutrition was estimated from the total number of children showing a decrease in weight-for-height/length (WFH) or Body Mass Index (BMI) z-scores from the time of admission to discharge. Logistic regression analysis was performed to determine associations between selected variables and weight loss during hospitalisation. Results: Albeit a borderline level of significance, a decrease in calculated z-scores occurred in 60.6% (Confidence Interval (CI) 53.1–67.6%) of children during hospitalisation with a mean weight decrease of 0.5 kg (Standard Deviation (SD) ± 3.37, p = 0.055). Children ≤ 60 months of age demonstrated a mean decrease in weight-for-height/length z-score of 0.145 (SD ± 0.73, p = 0.042); and those > 60 months, a mean decrease in BMI z-score of 0.152 (SD ± 0.39, p = 0.004). The majority with weight loss had been admitted with a diagnosis of gastroenteritis (81.2%), gastritis (64.3%) and pneumonia (55.6%). Weight loss was associated with duration of admission: 3 - 5 days (Odds Ratio (OR) 2.43, CI 1.46–4.03), 5 - 7 days (OR 4.67, CI 1.34–16.24), and > 7 days (OR 2.75, CI 0.88–8.64); score test for trend of odds is OR 1.37 (95% CI 1.11–1.69, p = 0.003). Conclusion: This study found a high incidence of hospital-acquired malnutrition in children. The most affected were those with gastroenteritis, gastritis and pneumonia. Hospital-acquired malnutrition was associated with an increased duration of hospitalisation.

Published
2018
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9. Prevalence and genetic diversity of rotavirus infection in children with acute gastroenteritis in a hospital setting, Nairobi Kenya in post vaccination era: a cross-sectional study

Author

Mary-Theresa Agutu, Julliette Ongus, Janeth Kombich, Rose Kamenwa, James Nyangao, John Kagira, Adelaide Ayoyi Ogutu, and Austine Bitek

Subjects
rotavirus, prevalence and genotype, vaccines, Medicine
Abstract

INTRODUCTION: rotavirus is the leading cause of severe diarrhoea among infants and young children. Each year more than 611 000 children die from rotavirus gastroenteritis, and two million are hospitalized, worldwide. In Kenya, the impact of recent rotavirus vaccinations on morbidities has not been estimated. The study aimed at determining the prevalence and identity of rotavirus strains isolated from rotavirus-associated diarrhoea in vaccinated children presenting with acute gastroenteritis. METHODS: two hundred and ninety eight specimen from children presented at Gertrude Childrens' Hospital from January to June 2012 were tested by EIA (Enzyme-linked Immunosorbent Assay) for rotavirus antigens. Molecular characterization was conducted on rotavirus-positive specimens. Extracted viral RNA was separated by polyacrylamide gel electrophoresis (PAGE) and the specific rotavirus VP4 (P-types) and VP7 (G-types) determined. RESULTS: the prevalence rate of rotavirus was 31.5% (94/298). Of the rotavirus dsRNA, 57 (60.1%) gave visible RNA profiles, 38 (40.4%) assigned long electropherotypes while 19 (20.2%) were short electropherotypes. The strains among the vaccinated were G3P [4], G12P [6], G3P [6], G9P [4], G mixed G9/3P [4] and G1/3P [4]. Specifically, the G genotypes were G9/3 (5.3%), G9 (4.3%), G3 (4.3%), G12 (2.1%) and mixed G1/3 (1.1%). The P genotypes detected were P [4] (5.3%) and P [6] (5.3%). CONCLUSION: the present study demonstrates diversity in circulating genotypes with emergence of genotypes G3, G9, G12 and mixed genotypes G9/3 and recommends that vaccines should be formulated with a broad range of strains to include G9 and G12.

Published
2017
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10. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Prebiotics

Author

Carlos A. Cuello-Garcia, Alessandro Fiocchi, Ruby Pawankar, Juan José Yepes-Nuñez, Gian Paolo Morgano, Yuan Zhang, Kangmo Ahn, Suleiman Al-Hammadi, Arnav Agarwal, Shreyas Gandhi, Kirsten Beyer, Wesley Burks, Giorgio W. Canonica, Motohiro Ebisawa, Rose Kamenwa, Bee Wah Lee, Haiqi Li, Susan Prescott, John J. Riva, Lanny Rosenwasser, Hugh Sampson, Michael Spigler, Luigi Terracciano, Andrea Vereda, Susan Waserman, Holger J. Schünemann, and Jan L. Brożek

Subjects
Immunologic diseases. Allergy, RC581-607
Abstract

Background The prevalence of allergic diseases in infants, whose parents and siblings do not have allergy, is approximately 10 % and reaches 20–30 % in those with an allergic first-degree relative. Intestinal microbiota may modulate immunologic and inflammatory systemic responses and, thus, influence development of sensitization and allergy. Prebiotics – non-digestible oligosaccharides that stimulate growth of probiotic bacteria – have been reported to modulate immune responses and their supplementation has been proposed as a preventive intervention.Objective The World Allergy Organization (WAO) convened a guideline panel to develop evidence-based recommendations about the use of prebiotics in the prevention of allergy.Methods The WAO guideline panel identified the most relevant clinical questions about the use of prebiotics for the prevention of allergy. We performed a systematic review of randomized controlled trials of prebiotics, and reviewed the evidence about patient values and preferences, and resource requirements (up to January 2015, with an update on July 29, 2015). We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations.Results Based on GRADE evidence to decision frameworks, the WAO guideline panel suggests using prebiotic supplementation in not-exclusively breastfed infants and not using prebiotic supplementation in exclusively breastfed infants. Both recommendations are conditional and based on very low certainty of the evidence. We found no experimental or observational study of prebiotic supplementation in pregnant women or in breastfeeding mothers. Thus, the WAO guideline panel chose not to provide a recommendation about prebiotic supplementation in pregnancy or during breastfeeding, at this time.Conclusions WAO recommendations about prebiotic supplementation for the prevention of allergy are intended to support parents, clinicians and other health care professionals in their decisions whether or not to use prebiotics for the purpose of preventing allergies in healthy, term infants.

Published
2016
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11. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Vitamin D

Author

Juan José Yepes-Nuñez, Alessandro Fiocchi, Ruby Pawankar, Carlos A. Cuello-Garcia, Yuan Zhang, Gian Paolo Morgano, Kangmo Ahn, Suleiman Al-Hammadi, Arnav Agarwal, Shreyas Gandhi, Kirsten Beyer, Wesley Burks, Giorgio W. Canonica, Motohiro Ebisawa, Rose Kamenwa, Bee Wah Lee, Haiqi Li, Susan Prescott, John J. Riva, Lanny Rosenwasser, Hugh Sampson, Michael Spigler, Luigi Terracciano, Andrea Vereda, Susan Waserman, Holger J. Schünemann, and Jan L. Brożek

Subjects
Immunologic diseases. Allergy, RC581-607
Abstract

Background The prevalence of allergic diseases is approximately 10 % in infants whose parents and siblings do not have allergic diseases and 20–30 % in those with an allergic first-degree relative. Vitamin D is involved in the regulation of the immune system and it may play a role in the development, severity and course of asthma and other allergic diseases.Objective The World Allergy Organization (WAO) convened a guideline panel to develop evidence-based recommendations addressing the use of vitamin D in primary prevention of allergic diseases.Methods Our WAO guideline panel identified the most relevant clinical questions and performed a systematic review of randomized controlled trials and non-randomized studies (NRS), specifically cohort and case-control studies, of vitamin D supplementation for the prevention of allergic diseases. We also reviewed the evidence about values and preferences, and resource requirements (up to January 2015, with an update on January 30, 2016). We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations.Results Having reviewed the currently available evidence, the WAO guideline panel found no support for the hypothesis that vitamin D supplementation reduces the risk of developing allergic diseases in children. The WAO guideline panel suggest not using vitamin D in pregnant women, breastfeeding mothers, or healthy term infants as a means of preventing the development of allergic diseases. This recommendation does not apply to those mothers and infants who have other indications for prophylactic or therapeutic use of vitamin D. The panel’s recommendations are conditional and supported by very low certainty evidence.Conclusions WAO recommendations about vitamin D supplementation for the prevention of allergic diseases support parents, clinicians and other health care professionals in their decisions whether or not to use vitamin D in preventing allergic diseases in healthy, term infants. Keywords: Allergic Diseases, Prevention, Vitamin D, Practice guidelines, GRADE

Published
2016
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12. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Probiotics

Author

Alessandro Fiocchi, Ruby Pawankar, Carlos Cuello-Garcia, Kangmo Ahn, Suleiman Al-Hammadi, Arnav Agarwal, Kirsten Beyer, Wesley Burks, Giorgio W Canonica, Motohiro Ebisawa, Shreyas Gandhi, Rose Kamenwa, Bee Wah Lee, Haiqi Li, Susan Prescott, John J Riva, Lanny Rosenwasser, Hugh Sampson, Michael Spigler, Luigi Terracciano, Andrea Vereda-Ortiz, Susan Waserman, Juan José Yepes-Nuñez, Jan L Brożek, and Holger J Schünemann

Subjects
Immunologic diseases. Allergy, RC581-607
Abstract

Background Prevalence of allergic diseases in infants, whose parents and siblings do not have allergy, is approximately 10% and reaches 20–30% in those with an allergic first-degree relative. Intestinal microbiota may modulate immunologic and inflammatory systemic responses and, thus, influence development of sensitization and allergy. Probiotics have been reported to modulate immune responses and their supplementation has been proposed as a preventive intervention.Objective The World Allergy Organization (WAO) convened a guideline panel to develop evidence-based recommendations about the use of probiotics in the prevention of allergy.Methods We identified the most relevant clinical questions and performed a systematic review of randomized controlled trials of probiotics for the prevention of allergy. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. We searched for and reviewed the evidence about health effects, patient values and preferences, and resource use (up to November 2014). We followed the GRADE evidence-to-decision framework to develop recommendations.Results Currently available evidence does not indicate that probiotic supplementation reduces the risk of developing allergy in children. However, considering all critical outcomes in this context, the WAO guideline panel determined that there is a likely net benefit from using probiotics resulting primarily from prevention of eczema. The WAO guideline panel suggests: a) using probiotics in pregnant women at high risk for having an allergic child; b) using probiotics in women who breastfeed infants at high risk of developing allergy; and c) using probiotics in infants at high risk of developing allergy. All recommendations are conditional and supported by very low quality evidence.Conclusions WAO recommendations about probiotic supplementation for prevention of allergy are intended to support parents, clinicians and other health care professionals in their decisions whether to use probiotics in pregnancy and during breastfeeding, and whether to give them to infants. Keywords: Allergy, Prevention, Probiotics, Practice guidelines, GRADE

Published
2015
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13. Prevalence and Endoscopic Findings of Helicobacter pylori Infection among Dyspeptic Patients in Kenya

Author

Smita Devani, Allan Rajula, Rose Kamenwa, Stephen Njoroge, Ahmed Laving, Andrew Nyerere, Catherine Mwangi, and Gunturu Revathi

Subjects
medicine.medical_specialty, medicine.diagnostic_test, biology, Esophagogastroduodenoscopy, business.industry, Peptic, Rapid urease test, Helicobacter pylori, medicine.disease, biology.organism_classification, Gastroenterology, Internal medicine, medicine, GERD, Medical history, Gastritis, medicine.symptom, business, Prospective cohort study
Abstract

Background: Helicobacter pylori is the most common cause of chronic human infections worldwide with the highest reported prevalence in Africa. It is associated with numerous upper gastrointestinal diseases such as gastritis, peptic ulcers, and gastric cancer. Endoscopic findings in the stomach usually associated with Helicobacter pylori infections include gastritis and gastro-esophageal reflux disease (GERD), however, these findings are suggestive but not diagnostic of Helicobacter pylori infection. Methods: This was a prospective study conducted between January 2018 and February 2019 at the Aga Khan University Hospital where dyspeptic patients scheduled for gastroduodenoscopy were enrolled. These patients were evaluated for Helicobacter pylori infection by rapid urease test, culture and histopathology. Diagnostic findings and patient history collected from medical files were documented and data analyzed. Results: A total of 487 dyspeptic patients undergoing esophagogastroduodenoscopy (EGD) were enrolled in the study and 199 dyspeptic patients were positive for Helicobacter pylori infection. The prevalence was 54.6% in males and 45.4% in females (p = 0.1546. The most common clinical indication and endoscopic findings were heart burn (25.2%) and gastritis (53.7%). Histopathology revealed that 86.1% of the dyspeptic patients had chronic active gastritis (p < 0.005) and 52.8% of them had H. pylori infection. Conclusions: Classical endoscopic findings such as GERD are not always indicative of H. pylori infection as its association with H. pylori infection was not statistically significant in this study.

Published
2020
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14. Comparing Diagnostic Performance of Pronto Dry Rapid Urease® and Culture to Histopathology among Endoscopy Patients at the Aga Khan University Hospital, Nairobi-Kenya

Author

Allan Rajula, Smita Devani, Catherine Mwangi, Nyamongo Onkoba, Fredrick Odhiambo, Gunturu Revathi, Stephen Njoroge, Kimang’a Nyerere, and Rose Kamenwa

Subjects
medicine.medical_specialty, medicine.diagnostic_test, biology, business.industry, Diagnostic test, General Medicine, Helicobacter pylori, University hospital, biology.organism_classification, Gastroenterology, Endoscopy, Internal medicine, Biopsy, Medicine, Histopathology, business
Abstract

Aim: This study sought to evaluate Pronto dry rapid urease® diagnostic test and compare its performance with culture. Study Design: Cross-sectional study. Place and Duration: From September 2017 to July 2018, across-sectional study was conducted at the Aga Khan University Hospital. Methodology: Patients attending endoscopy unit at the hospital were randomly sampled to provide gastric biopsy specimen. One specimen was tested for presence or absence of H. pylori using Pronto dry rapid urease® test and another specimen subjected to in vitro culture test which were then compared with histology reference results. Test validity and reliability was determined using Graph Pad Prism v5.01. Results: Of 274 study specimens, 121(44%) were positive for histology. Ninety-one (33%) of the study specimen were positive for culture compared to 147(54%) for Pronto dry rapid urease®. Pronto dry rapid urease® test had sensitivity of 100% (97.5%-100%) against 73.6% (64.8%-81.3%) for culture. Specificity was 96.1% (91.1%-98.7%) for Pronto dry rapid urease® compared to 35.3% (95% CI 24.1%-47.8%) for culture. Positive predictive value was 96.7% (92.5-98.9%) for Pronto dry rapid urease® compared to 97.8% (92.3%-99.7%) for culture. Negative predictive value was 100% (97%-100%) for Pronto dry rapid urease® against 82.5% (76.2%-87.7%) for culture. There was significant difference between both Pronto dry rapid urease® and culture test performance with histology in all validity measures, P< 0.001. On the other hand, there was no significant difference between Pronto dry rapid urease® and culture in all validity measures due to overlapping confidence intervals. Conclusion: Pronto dry rapid urease® out-performed culture in sensitivity and NPV. It would be the method of choice in H. pylori detection where histology is untenable and antimicrobial profiling which require culturing the bacterium is needless.

Published
2019
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15. Pre-albumin as a marker for predicting weight loss in hospitalised children

Author

William Macharia, Rose Kamenwa, Del-Rossi Sean Quadros, and Samuel Akech

Subjects
medicine.medical_specialty, Nutrition and Dietetics, business.industry, Medicine (miscellaneous), University hospital, Tertiary care, Pre albumin, 03 medical and health sciences, 0302 clinical medicine, Weight loss, 030225 pediatrics, 030220 oncology & carcinogenesis, Internal medicine, Positive predicative value, Medicine, Hospital malnutrition, weight loss, serum pre-albumin, medicine.symptom, business
Abstract

Objectives: This study sought to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Design: A hospital-based longitudinal survey was carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: A total of 170 children aged 29 days to 15 years who met the inclusion criteria were included in the study. Outcome measures: Serum pre-albumin levels and weight were measured at admission and repeated after 48–96 h. Sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Results: Of the 170 children studied, 57% and 60% had a drop in serum pre-albumin level and weight within the first four days of hospitalisation respectively. A drop in pre-albumin occurred in 68% of the 103 patients who had weight loss (p < 0.001). Using a serum pre-albumin cut off point of < 0.15 g/l at admission, sensitivity and specificity of serum pre-albumin in predicting weight loss were 76.7% and 29.0% (negative predictive value = 42.9%; positive predictive value = 64.2%). Positive and negative likelihood ratios were low at 1.08 and 0.8. The majority of the patients (72.3%) were already at risk of malnutrition as determined by the pre-albumin risk stratification on admission. Conclusion: Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation. It is, however, useful in identifying patients at risk of malnutrition on admission and during hospitalisation.

Published
2018
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16. Hospital-acquired malnutrition in children at a tertiary care hospital

Author

Samuel Akech, William Macharia, Rose Kamenwa, and Del-Rossi Sean Quadros

Subjects
0301 basic medicine, Pediatrics, medicine.medical_specialty, 030109 nutrition & dietetics, Nutrition and Dietetics, business.industry, Incidence (epidemiology), Medicine (miscellaneous), Anthropometry, Malnutrition in children, medicine.disease, Logistic regression, Confidence interval, 03 medical and health sciences, Malnutrition, 0302 clinical medicine, 030225 pediatrics, Statistical significance, medicine, anthropometric measurements, Body Mass Index z-scores, hospital acquired malnutrition, weight-for-height z-scores, business, Body mass index
Abstract

Objectives: This study sought to investigate the incidence and factors associated with hospital-acquired malnutrition in children. Design: A hospital-based longitudinal survey carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: One hundred and seventy children who met the inclusion criteria were included in the study. Outcome measures: Anthropometry was done at admission and discharge. Incidence of hospital-acquired malnutrition was estimated from the total number of children showing a decrease in weight-for-height/length (WFH) or Body Mass Index (BMI) z-scores from the time of admission to discharge. Logistic regression analysis was performed to determine associations between selected variables and weight loss during hospitalisation. Results: Albeit a borderline level of significance, a decrease in calculated z-scores occurred in 60.6% (Confidence Interval (CI) 53.1–67.6%) of children during hospitalisation with a mean weight decrease of 0.5 kg (Standard Deviation (SD) ± 3.37, p = 0.055). Children ≤ 60 months of age demonstrated a mean decrease in weight-for-height/length z-score of 0.145 (SD ± 0.73, p = 0.042); and those > 60 months, a mean decrease in BMI z-score of 0.152 (SD ± 0.39, p = 0.004). The majority with weight loss had been admitted with a diagnosis of gastroenteritis (81.2%), gastritis (64.3%) and pneumonia (55.6%). Weight loss was associated with duration of admission: 3 - 5 days (Odds Ratio (OR) 2.43, CI 1.46–4.03), 5 - 7 days (OR 4.67, CI 1.34–16.24), and > 7 days (OR 2.75, CI 0.88–8.64); score test for trend of odds is OR 1.37 (95% CI 1.11–1.69, p = 0.003). Conclusion: This study found a high incidence of hospital-acquired malnutrition in children. The most affected were those with gastroenteritis, gastritis and pneumonia. Hospital-acquired malnutrition was associated with an increased duration of hospitalisation.

Published
2017
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17. The global impact of the DRACMA guidelines cow's milk allergy clinical practice

Author

Holger J. Schünemann, Arabella Martelli, Jonathan M. Spergel, Lamia Dahdah, Ignacio J. Ansotegui, Sami L. Bahna, Raanan Shamir, Martin Bozzola, Yvan Vandenplas, Jan Brozek, Alessandro Fiocchi, Rose Kamenwa, Maria Said, Amal Assa'ad, Hugh A. Sampson, Mario Sánchez-Borges, Carina Venter, Roberto Berni Canani, Luigi Terracciano, Gary Wong, Haiqi Li, Susan Waserman, Ruby Pawankar, Gideon Lack, Motohiro Ebisawa, Christophe Dupont, Elena Galli, Clinical sciences, Growth and Development, Pediatrics, Fiocchi, Alessandro, Schunemann, Holger, Ansotegui, Ignacio, Assa'Ad, Amal, Bahna, Sami, Canani, Roberto Berni, Bozzola, Martin, Dahdah, Lamia, Dupont, Christophe, Ebisawa, Motohiro, Galli, Elena, Li, Haiqi, Kamenwa, Rose, Lack, Gideon, Martelli, Alberto, Pawankar, Ruby, Said, Maria, Sánchez-Borges, Mario, Sampson, Hugh, Shamir, Raanan, Spergel, Jonathan, Terracciano, Luigi, Vandenplas, Yvan, Venter, Carina, Waserman, Susan, Wong, Gary, and Brozek, Jan

Subjects
Pulmonary and Respiratory Medicine, 030201 allergy, medicine.medical_specialty, Oral food challenge, business.industry, Immunology, Scopus, MEDLINE, Public policy, Milk allergy, Review, medicine.disease, 03 medical and health sciences, 0302 clinical medicine, 030228 respiratory system, Food allergy, Family medicine, medicine, Immunology and Allergy, Overdiagnosis, Grading (education), business, health care economics and organizations
Abstract

Background: The 2010 Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines are the only Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines for cow's milk allergy (CMA). They indicate oral food challenge (OFC) as the reference test for diagnosis, and suggest the choice of specific alternative formula in different clinical conditions. Their recommendations are flexible, both in diagnosis and in treatment. Objectives & methods: Using the Scopus citation records, we evaluated the influence of the DRACMA guidelines on milk allergy literature. We also reviewed their impact on successive food allergy and CMA guidelines at national and international level. We describe some economic consequences of their application. Results: DRACMA are the most cited CMA guidelines, and the second cited guidelines on food allergy. Many subsequent guidelines took stock of DRACMA's metanalyses adapting recommendations to the local context. Some of these chose not to consider OFC as an absolute requirement for the diagnosis of CMA. Studies on their implementation show that in this case, the treatment costs may increase and there is a risk of overdiagnosis. Interestingly, we observed a reduction in the cost of alternative formulas following the publication of the DRACMA guidelines. Conclusions: DRACMA reconciled international differences in the diagnosis and management of CMA. They promoted a cultural debate, improved clinician's knowledge of CMA, improved the quality of diagnosis and care, reduced inappropriate practices, fostered the efficient use of resources, empowered patients, and influenced some public policies. The accruing evidence on diagnosis and treatment of CMA necessitates their update in the near future.

Published
2018

18. Prevalence and genetic diversity of rotavirus infection in children with acute gastroenteritis in a hospital setting, Nairobi Kenya in post vaccination era: a cross-sectional study

Author

Adelaide Ayoyi Ogutu, Austine Bitek, Janeth Kombich, Rose Kamenwa, John Kagira, Mary-Theresa Agutu, Julliette Ongus, and James Nyangao

Subjects
Diarrhea, Male, 0301 basic medicine, Genotype, Cross-sectional study, viruses, 030106 microbiology, Prevalence, Enzyme-Linked Immunosorbent Assay, medicine.disease_cause, Rotavirus Infections, 03 medical and health sciences, Rotavirus, medicine, prevalence and genotype, Humans, Antigens, Viral, Genetic diversity, lcsh:R5-920, business.industry, Research, lcsh:Public aspects of medicine, Infant, Newborn, Genetic Variation, Infant, virus diseases, lcsh:RA1-1270, General Medicine, Acute gastroenteritis, vaccines, Kenya, Virology, Gastroenteritis, Rotavirus infection, Vaccination, Cross-Sectional Studies, rotavirus, Rotavirus, prevalence and genotype, vaccines, Child, Preschool, Acute Disease, RNA, Viral, Electrophoresis, Polyacrylamide Gel, Female, business, lcsh:Medicine (General)
Abstract

INTRODUCTION: rotavirus is the leading cause of severe diarrhoea among infants and young children. Each year more than 611 000 children die from rotavirus gastroenteritis, and two million are hospitalized, worldwide. In Kenya, the impact of recent rotavirus vaccinations on morbidities has not been estimated. The study aimed at determining the prevalence and identity of rotavirus strains isolated from rotavirus-associated diarrhoea in vaccinated children presenting with acute gastroenteritis. METHODS: two hundred and ninety eight specimen from children presented at Gertrude Childrens’ Hospital from January to June 2012 were tested by EIA (Enzyme-linked Immunosorbent Assay) for rotavirus antigens. Molecular characterization was conducted on rotavirus-positive specimens. Extracted viral RNA was separated by polyacrylamide gel electrophoresis (PAGE) and the specific rotavirus VP4 (P-types) and VP7 (G-types) determined. RESULTS: the prevalence rate of rotavirus was 31.5% (94/298). Of the rotavirus dsRNA, 57 (60.1%) gave visible RNA profiles, 38 (40.4%) assigned long electropherotypes while 19 (20.2%) were short electropherotypes. The strains among the vaccinated were G3P [4], G12P [6], G3P [6], G9P [4], G mixed G9/3P [4] and G1/3P [4]. Specifically, the G genotypes were G9/3 (5.3%), G9 (4.3%), G3 (4.3%), G12 (2.1%) and mixed G1/3 (1.1%). The P genotypes detected were P [4] (5.3%) and P [6] (5.3%). CONCLUSION: the present study demonstrates diversity in circulating genotypes with emergence of genotypes G3, G9, G12 and mixed genotypes G9/3 and recommends that vaccines should be formulated with a broad range of strains to include G9 and G12.

Published
2017

19. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Probiotics

Author

Juan José Yepes-Nuñez, Giorgio Walter Canonica, Bee Wah Lee, Rose Kamenwa, Luigi Terracciano, Suleiman Al-Hammadi, Holger J. Schünemann, Andrea Vereda-Ortiz, Jan Brozek, Michael Spigler, Susan L. Prescott, Kirsten Beyer, Haiqi Li, Carlos A. Cuello-Garcia, Wesley Burks, Ruby Pawankar, Alessandro Fiocchi, Kangmo Ahn, Shreyas Gandhi, Susan Waserman, Arnav Agarwal, Hugh A. Sampson, Motohiro Ebisawa, John J. Riva, and Lanny J. Rosenwasser

Subjects
lcsh:Immunologic diseases. Allergy, Pulmonary and Respiratory Medicine, Allergy, medicine.medical_specialty, GRADE, Practice guidelines, Prevention, Probiotics, Immunology, Breastfeeding, MEDLINE, Alternative medicine, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, Position Article and Guidelines, Health care, medicine, Immunology and Allergy, 030212 general & internal medicine, Intensive care medicine, Pregnancy, business.industry, Guideline, medicine.disease, 030228 respiratory system, lcsh:RC581-607, business
Abstract

Background Prevalence of allergic diseases in infants, whose parents and siblings do not have allergy, is approximately 10% and reaches 20–30% in those with an allergic first-degree relative. Intestinal microbiota may modulate immunologic and inflammatory systemic responses and, thus, influence development of sensitization and allergy. Probiotics have been reported to modulate immune responses and their supplementation has been proposed as a preventive intervention. Objective The World Allergy Organization (WAO) convened a guideline panel to develop evidence-based recommendations about the use of probiotics in the prevention of allergy. Methods We identified the most relevant clinical questions and performed a systematic review of randomized controlled trials of probiotics for the prevention of allergy. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. We searched for and reviewed the evidence about health effects, patient values and preferences, and resource use (up to November 2014). We followed the GRADE evidence-to-decision framework to develop recommendations. Results Currently available evidence does not indicate that probiotic supplementation reduces the risk of developing allergy in children. However, considering all critical outcomes in this context, the WAO guideline panel determined that there is a likely net benefit from using probiotics resulting primarily from prevention of eczema. The WAO guideline panel suggests: a) using probiotics in pregnant women at high risk for having an allergic child; b) using probiotics in women who breastfeed infants at high risk of developing allergy; and c) using probiotics in infants at high risk of developing allergy. All recommendations are conditional and supported by very low quality evidence. Conclusions WAO recommendations about probiotic supplementation for prevention of allergy are intended to support parents, clinicians and other health care professionals in their decisions whether to use probiotics in pregnancy and during breastfeeding, and whether to give them to infants. Electronic supplementary material The online version of this article (doi:10.1186/s40413-015-0055-2) contains supplementary material, which is available to authorized users.

Published
2015
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