- Addressing practice gaps in identification & intervention practices will improve outcomes and reduce costs
- Growing role for CMPA awareness and engagement tools
Epalinges, Switzerland, 29 November 2017– Pointing the way forward for primary healthcare practitioners in the quest for earlier identification and informed intervention for Cow’s Milk Protein Allergy (CMPA), new research data on real world clinical practice was revealed at the EAACI Pediatric Allergy and Asthma meeting (PAAM)1 held in London between 26-28 October 2017.
CMPA impacts up to 3% of infants, making it one of the most common food allergies in this age group2. However, in most cases, it is non-IgE mediated and effective therapeutic interventions can be delayed – sometimes for several months - due to the difficulties primary healthcare professionals face interpreting the range of potential non-specific symptoms such as crying, regurgitation, stool consistency and frequency, skin and respiratory issues. Currently, CMPA can only be confirmed by an elimination diet followed by a food challenge.
Improvement opportunities and cost saving potential
At PAAM, a ‘quality of care’ survey on CMPA diagnosis and management in Europe - as evaluated against the 2012 ESPGHAN CMPA guidelines3 - was presented by Dr. Katharina Werkstetter from Dr.von Hauner Children’s Hospital Klinikum, Ludwig-Maximilians-Universität München. The online survey4 spanned 13 European countries and 2551 respondents (86% pediatricians), revealing widespread knowledge and practice gaps when asked how they would handle a range of different case scenarios.
For example, while 67.7% correctly identified an elimination diet and food challenge as the right option to rule out CMPA for a 10-month old infant with chronic diarrhea and failure to thrive, 19.1% suggested incorrectly it was identifiable via IgE against CMPA in the blood. Furthermore, it highlighted some confusion about what type of formula to prescribe as 19.1% of respondents incorrectly agreed that it is acceptable to prescribe a partially hydrolyzed infant formula for an infant with CMPA refusing extensively hydrolyzed formula (eHF). Even more worrying is that 51% suggested that in these circumstances, it was appropriate to switch to soy-based formula and 11% to goat milk formula, respectively. According to the ESPGHAN as well as the EAACI Guidelines, all these options would present a safety risk.
Professor Sibylle Koletzo from Dr. von Hauner Children’s Hospital, said, “Early identification and appropriate intervention for CMPA is vital for healthy infant development. The survey points to where we need to improve clinical practice in relation to the ESPGHAN guidelines and this should be the focus of knowledge sharing and training going forward.”
Shedding further light on CMPA management gaps and formula choice was a presentation of ‘Treatment patterns in patients with CMPA in a German sickness fund database5. The analysis revealed that - contrary to current recommendations – extensively hydrolyzed formula (eHF) is prescribed as first-line treatment in less than 50% of infants with CMPA in the analyzed population. Amino Acid-based Formula (AAF) is consequently being over-prescribed, as according to the current guidelines, it should be reserved for those with severe or life threatening symptoms or for those not tolerating an eHF.
Moreover, the use of eHF as first-line treatment is associated with more efficient use of health care budget as the AAF-group had higher costs for the treatment compared to the eHF group.
Growing role of awareness and engagement tools
Leveraging the increased understanding of the challenges primary healthcare professionals experience in managing CMPA, experts and industry are collaborating to bring forward innovative tools to help practitioners and to engage parents. These tools enable the tracking and assessment of non-specific symptoms, and the likelihood of CMPA, so that therapeutic options can be considered much earlier.
The latest example is a new mobile application called SmilesBack®, presented for the first time at the PAAM in London. SmilesBack® has been developed by Nestlé Health Science together with allergy experts and parents. The app, which also includes a CMPA learning section, enables parents to digitally record the frequency and type of feeding as well as non-specific symptoms. The app can create a succinct one-page report for sharing with their healthcare professional electronically or in printed form. The healthcare professional, when meeting face to face with the parent and infant, can then apply the app data to the Cow’s Milk-related Symptom Score (CoMiSS®) to assess and interpret symptoms and the likelihood of CMPA.
The CoMiSS® scoring is based upon the frequency and type of non-specific symptoms. An overall score of 12 or higher helps identify infants likely to have CMPA, with a predictive accuracy of around 75%6. The CoMiSS® was launched in 2015 and like the SmilesBack® application was also developed by top international experts. It is available in 13 languages, in either hard copy or digital format.
Philippe Eigenmann, Associate Professor, Department of Pediatrics, Université de Genève, Switzerland, commented, “The CoMiSS is proving a valuable tool to help primary healthcare professionals make sense of symptoms and shorten the journey to diagnosis and successful intervention. The SmilesBack app, with lots of helpful reminders and tips, makes accurate collection of symptoms and feeds really easy for the parents, rather than relying on memory or notes when they sit down and talk with their healthcare professional. With the app providing the data needed at the tap of a button, completing the CoMiSS becomes even easier and faster for the healthcare professional.”
Notes to Editors
- CoMiSS link to page and publication:
- Nestlé Health Science press release on CoMiSS:
- Additional article on CoMiSS :
Links to other educational resources:
- NHSc Website:
- Links to proceedings and videos from a Satellite Symposium held at EAACI in Helsinki ‘Controversies on Special Products for Managing Cow’s Milk Protein Allergy in Infants - ‘Safety and Suitability’:
- Nestlé Nutrition Institute resources:
- EACCI is the European Academy of Allergy and Clinical Immunology: The Pediatric Allergy and Asthma Meeting (PAAM 2017, 26-28 October 2017) was a focused meeting held under the auspices of EAACI. http://www.eaaci.org/focused-meetings/paam-2017
- Høst A. Frequency of cow’s milk allergy in childhood. Ann Allergy Asthma Immunol 2002;89(Sup1):33-7.
- Koletzko, S., Niggermann, B., Arato, A., et al. 2012. Diagnostic approach and management of cow’s milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr, 55(2),pp.221-9
- Diagnosis and management of cow’s milk protein allergy - how big is the gap between ideal and reality? A quality-of-care survey in Europe: A poster presentation at EACCI PAAM 2017 http://www.eaaci.org/meetings/PAAM2017-Abstracts/abstracts/PAAM2017_P66.pdf
- Treatment patterns in patients with cow’s milk protein allergy (CMPA) in a German Sickness Fund database: 2017. http://www.eaaci.org/meetings/PAAM2017-Abstracts/abstracts/PAAM2017_D46.pdf
- Vandenplas Y, Steenhout P, Järvi A et al. Pooled Analysis of the Cow's Milk-related-Symptom-Score (CoMiSS™) as a Predictor for Cow's Milk Related Symptoms. Pediatr Gastroenterol Hepatol Nutr. 2017 Mar;20(1):22-26.