Clinical Commentary Review
When Should Infants with Cow’s Milk Protein Allergy Use an Amino Acid Formula? A Practical Guide
Rosan Meyer, PhDa, Marion Groetch, MScb, and Carina Venter, PhDc London, United Kingdom; New York, NY; and Denver, Colo
American Academy of Allergy, Asthma & Immunology (J Allergy Clin Immunol Pract 2018;6:383-99)
Cow’s milk protein allergy (CMPA) is the most common food allergy in childhood and its prevalence ranges between 1.9% and 4.9%. Most children present with CMPA at age less than 1 year and therefore may require a hypoallergenic formula in the absence of breast milk. Hypoallergenic formulas include both extensively hydrolyzed formula (EHF) and amino acid formula (AAF). For most children with a CMPA, an EHF will be sufficient for symptom resolution, as reflected in current guidelines, but there is a subset of children with CMPA where an AAF may be indicated.
牛奶蛋白过敏（CMPA）是幼儿最常见的食物过敏，患病率在1.9%至4.9%之间。大多数牛奶蛋白过敏患儿发生在一岁以前，所以在不能母乳喂养时需要用低敏配方奶替代。 低敏配方包括深度水解配方（EHF）和氨基酸配方（AAF）。大部分CMPA患儿服用EHF可以改善过敏症状，目前一些相关指南也有相应内容的描述，但一些CMPA患儿的治疗仍然需要服用AAF。
The appropriate use of an AAF is a highly debated topic, because there is a significant fiscal burden to either the health care system or the parents. From the literature, the following themes were identified as possible reasons for choosing an AAF: (1) symptoms not fully resolved on EHF, (2)faltering growth/failure to thrive, (3) multiple food eliminations,(4) severe complex gastrointestinal food allergies, (5) eosinophilic esophagitis, (6) food protein induced enterocolitis syndrome, (7) severe eczema, and (8) symptoms while breastfeeding.
如何合理使用AAF目前还非常有争议，因为不管是对于儿童保健机构还是家庭父母来说，相应的财务负担和家庭花费都非常大。 从这篇文献资料看，以下几类情况是可能需要选择AAF的：
1）使用EHF不能缓解的患儿；
2）存在生长发育迟缓/停滞的患儿；
3）多种食物过敏患儿；
4）严重复杂的胃肠道食物过敏;
5） 嗜酸细胞性食管炎；
6）食物蛋白诱导的的小肠结肠炎综合征（FPIES）；
7）严重湿疹；
母乳喂养仍发生过敏症状
指南对于不同临床表现的首选推荐配方
CONCLUSIONS
The appropriate use of an AAF versus an EHF is a highly debated topic, in particular because it has a significant cost implication for health care systems and parents, but also because the well-being of the child with a CMPA needs to be taken into account. For most children with CMPA, an EHF will lead to symptom resolution, but there is a cohort that will require an AAF. On the basis of our literature review, children more likely to benefit from an AAF mostly show complex disease presentations (multiple foods involved, severe AD, and/or gastrointestinal symptoms), with growth issues. It is therefore important that health care professionals perform a detailed allergy-focused history to help them make this decision. A blanket approach for using an AAF is not advised, in particular with the emergence of new data of tolerance development using specific hypoallergenic formulas with addition of probiotics, prebiotics, and synbiotics, which may in future further influence formula choice.
合理使用AAF抑或EHF目前存在很大争议，尽管对医疗保健机构和家庭父母来说，经济压力是非常明显的，但CMA患儿的健康状况应该是必需考虑的。对于大多数牛奶蛋白过敏的患儿来说，EHF能改善其过敏症状，但仍有些患者需要使用AAF。基于我们一些文献回顾，发现更能够获益于AAF的患儿通常存在复杂的疾病表现（存在多种食物过敏，或是严重的特应性皮炎或/和具有胃肠道症状），以及生长发育不良。医务人员认真细致地采集过敏史，可以帮助进行判断。对于AAF的推荐没有全面绝对的建议，特别是目前出现一些新的添加了益生菌/益生元/合生元的低敏配方对口服耐受建立方面的资料， 也会影响配方的选择。
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