Retrospective Cohort Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. Mar 9, 2025; 14(1): 100386
Published online Mar 9, 2025. doi: 10.5409/wjcp.v14.i1.100386
Clinical, laboratory, and therapeutic differences between immunoglobulin E-mediated and non-immunoglobulin E-mediated cow’s milk protein allergy in children
Hasan M Isa, Marwa J Abdulnabi, Nawra S Naser, Fatema N Lahmda, Noor M AlAnsari, Zahra H Isa, Afaf M Mohamed
Hasan M Isa, Marwa J Abdulnabi, Nawra S Naser, Fatema N Lahmda, Noor M AlAnsari, Department of Pediatrics, Salmaniya Medical Complex, Manama 26671, Bahrain
Hasan M Isa, Department of Pediatrics, Arabian Gulf University, Manama 26671, Bahrain
Zahra H Isa, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
Afaf M Mohamed, Public Health Directorate, Ministry of Health, Manama 26671, Bahrain
Author contributions: Isa HM was the main contributor in study design, literature review, data analysis, drafting manuscript, and oversight for all phases of the project and the final approval of the version to be published; Abdulnabi MJ was responsible for literature review, data collection, data analysis, drafting and revising manuscript; Naser NS, Lahmeda FN, and AlAnsari NM were responsible for literature review, data collection, drafting and revising manuscript; Isa ZH was responsible for data collection, drafting and revising manuscript; Mohamed AM was responsible for data collection and revising manuscript; all the authors have read and approved the final manuscript.
Institutional review board statement: This study was conducted in accordance with the Principles of Helsinki Declaration and Received Ethical Approval from the Research and Research Ethics Committee at Salmaniya Medical Complex, Government Hospitals, Manama, Bahrain (No. 30036216, December 6, 2016).
Informed consent statement: Consent was not needed as the study was retrospective without exposure to the patient’s data. However, parental consent was obtained to publish the children’s photographs, and patient confidentiality was maintained by covering their eyes to obscure their identities.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Data are available upon reasonable request.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hasan M Isa, MBChB, Associate Professor, Consultant Physician-Scientist, Department of Pediatrics, Salmaniya Medical Complex, 2904 Al Salmaniya Area, PO Box 12, Manama 26671, Bahrain. halfaraj@hotmail.com
Received: August 14, 2024
Revised: October 8, 2024
Accepted: November 12, 2024
Published online: March 9, 2025
Processing time: 127 Days and 10.9 Hours
Abstract
BACKGROUND

Although breast milk is ideal for newborns, in some cases, it is replaced with cow’s milk, which contains proteins that increase the risk of cow’s milk protein allergy (CMPA).

AIM

To evaluate CMPA prevalence in Bahrain and compare clinical characteristics of children with immunoglobulin E (IgE)- and non-IgE-mediated CMPA.

METHODS

This retrospective cohort study examined children with CMPA diagnosed at the pediatric gastroenterology outpatient clinic of the Salmaniya Medical Complex, Bahrain, between 2014 and 2022, and assessed CMPA prevalence. Clinical presentations, laboratory findings, dietary modifications, and outcomes were compared between children with IgE-mediated and non-IgE-mediated CMPA. Categorical variables were compared using Fisher’s exact test or Pearson’s χ2 test, whereas continuous variables were compared using Student’s t-test or the Mann-Whitney U test.

RESULTS

Of 8332 patients, 6022 (72.3%) adhered to their appointment. Of them, 618 (10.3%) were suggested of having CMPA and 595 (96.3%) were included; CMPA prevalence was 2%. Most patients were Bahraini (93.8%) and males (55.3%). Non-IgE-mediated type accounted for 77.3% cases and IgE-mediated type, 22.7%. IgE-mediated CMPA presented more in boys (P = 0.030), and later in life (5.1 months ± 4.5 months vs 4.2 months ± 4.2 months, P = 0.016, 95%CI: 0.08-1.73), had more associated diseases (P < 0.001); and presented with more cutaneous (P = 0.024) and respiratory (P = 0.003) manifestations, severe symptoms [rash/dry skin (P = 0.031), facial swelling/angioedema (P = 0.003), failure to thrive (P = 0.013), apparent life-threatening event (P < 0.001)], and positive physical findings (P = 0.002) than non-IgE-mediated CMPA. Most patients were exclusively fed cow milk formula (50.3%). The amino acid-based formula (AAF) was most prescribed (60.5%) with no difference between the two types (P = 0.173). Although breastfeeding was recommended to 49.6%, only 8.2% were exclusively breastfed. IgE-mediated CMPA was associated with a longer follow-up duration than non-IgE-mediated CMPA (17.3 months ± 14.0 months vs 13.5 months ± 13.4 months, P = 0.005, 95%CI: 1.1-6.3).

CONCLUSION

This study revealed a high CMPA prevalence with clinical differences between both types that can influence treatment. AAF was most prescribed, while breastfeeding with dietary modification is rarely applied.

Keywords: Children; Milk allergy; Immunoglobulin E; Breastfeeding; Infant formula; Bahrain

Core Tip: The prevalence of cow’s milk protein allergy (CMPA) in children in Bahrain and differences between immunoglobulin E (IgE)-mediated and non-IgE-mediated allergies have not been studied previously. In this retrospective cohort study, we found that CMPA, commonly the non-IgE-mediated type, affects 10.3% of children among those visiting outpatient pediatric gastroenterology clinics. IgE-mediated CMPA presents with more severe symptoms and physical findings than non-IgE-mediated CMPA. Despite being common, CMPA diagnosis depends on the clinical presentation. Amino acid-based formulas are frequently prescribed, whereas exclusive breastfeeding and maternal dietary restrictions are underutilized. Therefore, breastfeeding children with CMPA should be encouraged.