THE COW’S MILK ELIMINATION AND PROVOCATION TEST

(Use of Amino Acid Formula During Elimination)

Zakiudin Munasir
Professor Doctor Zakiudin Munasir is Head of the Division of Allergy and Immunology, Department of Child Health in the Faculty of
Medicine, University of Indonesia - Cipto Mangunkusumo Hospital.

He completed his medical degree at the University of Indonesia, Jakarta, Indonesia and residency in paediatrics.

Professor Munasir subsequently became a pediatric consultant in allergy and immunology for the Indonesian Pediatric Society.

Professor Munasir is a member of the working group on allergy and immunology for the Indonesian Pediatric Society and also a
member of the Indonesian Allergy and Immunology Association.

He is a member of the European Pediatric Allergy Rheumatology, the World Allergy Organization, the European Academy of Allergy
and Clinical Immunology and board member of Asia Pacific Association of Pediatric Allergy, Respirology & Immunology (APAPARI).

He is also an editor for the Asia Pacific Allergy Journal.

Prof. DR. Dr. Zakiudin MUNASIR, SpA(K)

Division of Allergy and Clinical Immunology, University of Indonesia, Jakarta,

Indonesia
Prevalence
• Around 20% among children <1 year of age experience reaction
against food including food allergy.
• US Agriculture Dept: 15 % of population has allergy against
food or ingredients.
• Atopic dermatitis is the most manifestation of food allergy in
children.
 Clinical Symptoms

Mostly affect GI tract due to its first contact:

swollen & itchy lips up to up to severe bloody

abdominal pain & cramps vomiting
tongue and oropharynx diarrhea
 Allergy - Prevalence

Cow’s milk protein is the second most common Indonesia national data is lacking
food allergen in young Asian children, after egg

Lee AJ, Thalayasingam M, Lee BW, Asia Pac Allergy 2013;3:3-14

 Sensitization on atopic dermatitis patients in
Pediatric Allergy Clinic (2011, 2013)

2. Sidabutar S, et al. Sari Pediatri. 2011;13:147-51.

3. Munasir ZM, Muktiarti D. Asia Pac Allergy. 2013; 3: 23–8.
Patofisiologi Reaksi Alergi
 The Fraction/protein Allergen g/l ~30 % Total MW (kDa) AA PI

proteins
[1] protein 80
Caseins
in cow’s Alphas1-casein 12-15 29 23.6 199 4.9-5.0

milk Alphas2-casein 3-4 8 25.2 207 5.2-5.4

Beta-casein 9-11 27 24.0 209 5.1-5.4

Gamma1-casein Bos d 8 20.6 180 5.5

Gamma2-casein 1-2 6 11.8 104 6.4

Gamma3-casein 11.6 102 5.8

Kappa-casein 3-4 10 19.0 169 5.4-5.6

~5.0 20
Whey proteins
Alpha-lactalbumin Bos d 4 1-1.5 5 14.2 123 4.8
Beta-lactoglobulin Bos d 5 3-4 10 18.3 162 5.3
Immunoglobulin Bos d 7 0.6-1.0 3 160.0 - -
BSA Bos d 6 0.1-0.4 1 67.0 583 4.9-5.1
Lactoferrin - 0.09 traces 800.0 703 8.7
AA = Amino acids; BSA = bovine serum albumin.

Alessandro F, et al. Cow’s Milk Allergy in Children and Adults.

 Atopic Dermatitis

Infantile colic
CMPA-
suspected Gastro-esophageal
Symptoms reflux
Milk diarrhea and rectal
bleeding
Other GI symptoms
Vomiting, chronic
diarrhea, failure to
thrive

Apps JR and Beattie RM, BMJ 2009:339:b2275

 The spectrum of conditions associated with IgE-mediated reactions to cow’s milk

I Systemic IgE-mediated reactions (anaphylaxis)

A Immediate-onset reactions
B Late-onset reactions

II IgE-mediated gastrointestinal reactions

A Oral allergy syndrome
B Immediate gastrointestinal allergy

III IgE-mediated respiratory reactions

A Asthma and rhinitis secondary to ingestion of milk
B Asthma and rhinitis secondary to inhalation of milk (e.g. occupational asthma)

IV IgE-mediated cutaneous reactions

A Immediate-onset reactions
1. Acute urticarial or angioedema
2. Contact urticarial
B Late-onset reactions
Atopic dermatitis

Boyce JA, Assa’ad A, Burks AW, et al: Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J. Allergy Clin Immunol 2010;126(6
suppl):S1-S58.
Essential Components of Allergy Diagnosis

Anamnesis dan Pemeriksaan Fisis

Symptoms versus Exposure

Diagnostic Confirmatory Test

Skin Test (Puncture, Intradermal)
Allergen-specific IgE antibody serology

Provocation Test
Oral, Nasal, Bronchiall
Essential Components of
Allergy Diagnosis

Anamnesis dan Pemeriksaan Fisis

Symptoms versus Exposure

Diagnostic Confirmatory Test

Skin Test (Puncture, Intradermal)
Allergen-specific IgE antibody serology

Provocation Test
Oral, Nasal, Bronchiall
 Basic Concept of Allergy Diagnosis

• Anamnesis : Symptoms and allergen

• Physical examination :
Allergy disease suspicion : Skin Prick Test or specific
IgE test1-3 or Oral Provocation Test

1. Oppenheimer Ann Allergy 2006;S1:6-12,

2. Bousquet Clin Allergy 17:529-36, 1987
3. Cockroft Am Rev Respir Dis 135:264-7., 1987
 Allergy History

• Demographics (age)
• Symptoms: frequency and severity
• Pattern: intermittent, persistent or seasonal
• Response to environmental factors:
• Changes in temperature, smells, humidity, alcohol Jobs
and hobbies Identify allergens/irritants at home, school or
the environment
• Current and past treatment: effectiveness, adherence and
side effects
Allergen-specific IgE
In-vitro and In-vivo tests
In-vitro In-vivo
IgE Antibody SPT
Serology
High sensitivity Yes Yes
High specificity Yes Yes
High reproducibility Yes Yes
Quantitative results in kIU/L Yes No
WHO Standard calibrated Yes No
Quality assurance test program Yes No

Can be used independently Yes No

of pharmaceutical treatment

Can be used independently Yes No

of patient skin status
Time factor 1-7 days 15-30 minutes
Cost factor more expensive inexpensive
Usefulness in motivating patients obscure dramatic
Skin Prick Test for food allergen
and DBPCFC

• PPV of positive SPT - <50% vs DBPCFC

• NPV of negative SPT - >95% vs DBPCFC

Allergy skin prick testing

Skin prick test / positive result

 The drug use’s influence in Skin Prick Test

Most antihistamines and antidepressants suppress the

response in the skin for 3-7 days.
Astemizole even suppresses 1-3 months.
H2 antagonists do not interfere with skin tests.
Bronchodilators do not interfere with skin testing.
Low-dose steroids and short use also do not interfere with
skin tests.
Cook J Allergy Clin Immunol 1973;51:71-7
Rao KS J Allergy Clin Immunol 1988;82:752-7
Miller J J Allergy Clin Immunol 1989;84:895-99
Slott RIJ Allergy Clin Immunol 1974;554:229-34
The relationship between SPT size and the
possibility of open provocation is positive

milk egg peanut

Children 0-2yrs ≥6mm ≥ 5mm ≥ 4mm

Children all ages ≥ 8mm ≥ 7mm ≥ 8mm

Sporik et al Clin Exp Allergy 2000;30

Allergen-specific IgE
In-vitro and In-vivo tests
In-vitro In-vivo
IgE Antibody SPT
Serology
High sensitivity Yes Yes
High specificity Yes Yes
High reproducibility Yes Yes
Quantitative results in kIU/L Yes No
WHO Standard calibrated Yes No
Quality assurance test program Yes No

Can be used independently Yes No

of pharmaceutical treatment

Can be used independently Yes No

of patient skin status
Time factor 1-7 days 15-30 minutes
Cost factor more expensive inexpensive
Usefulness in motivating patients obscure dramatic
 A patient is
reported with
possible symptoms
of IgE-mediated
CMA. The
probability of CMA
is average, but the
challenge is difficult
to perform. Her SPT
is positive. What
can I get from an in
vitro specific igE
determination?

[Terraciano L, Schunemann H, Brozek J, et al: How DRACMA changes clinical decision for the individual patient in
CMA therapy. Curr Opin Allergy Clin Immunol 2012;12:316-322.]
 Diet:
Free of cow’s milk protein
 Utrecht University

Compounds with immunological

properties in human milk

Oligosaccharides

Field J Nutr 2005

 Feeding and Formula Options for
Infants with CMA
Breast milk with
maternal diet restriction

Extensively hydrolyzed • Contains only peptides that have a MW <3,000 d

formula (eHF) • Soy-based formula

Free amino acid-based • peptide-free formulas that contain mixtures of essential

formula (AAF) and nonessential amino acids

Formulas that should • Partially hydrolyzed formula (pHF) - Contains reduced

NOT be used oligopeptides that have a MW generally <5,000 d

Greer FR, et al. Pediatrics 2008;121:183-91

SENSITIZATION
 Technologies to Reduce the
Allergenicity of a Protein
Heating

Enzymatic hydrolysis

Ultrafiltration

The lower the chain length and the smaller the molecular mass, the lower is the residual
allergenicity of a protein / peptide
Protein Hydrolysates: Different Types

intact protein pHF eHF Amino acids

Allergenicity
 Soy formula is recommended as first choice for infants over 6 months of
age with immediate food reactions, and for those with gastrointestinal
symptoms or atopic dermatitis in the absence of failure to thrive.

Amino acid formula is recommended as first choice in anaphylaxis and

eosinophilic oesophagitis.

If treatment with the initial formula is not successful, use of an alternative

formula is recommended

MJA 2008; 188: 109–112

J Clin Allerg Immunol 2003; 112:S118-27
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