Next Article in Journal
Activation of Insulin Signaling in Adipocytes and Myotubes by Sarcopoterium Spinosum Extract
Next Article in Special Issue
Differential Effects of Dry vs. Wet Heating of β-Lactoglobulin on Formation of sRAGE Binding Ligands and sIgE Epitope Recognition
Previous Article in Journal
Dietary Composition and Effects in Inflammatory Bowel Disease
Previous Article in Special Issue
Individual Sensitization Pattern Recognition to Cow’s Milk and Human Milk Differs for Various Clinical Manifestations of Milk Allergy
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:

Cow’s Milk Allergy: Immunomodulation by Dietary Intervention

Enza D’Auria
Silvia Salvatore
Elena Pozzi
Cecilia Mantegazza
Marco Ugo Andrea Sartorio
Licia Pensabene
Maria Elisabetta Baldassarre
Massimo Agosti
Yvan Vandenplas
5 and
GianVincenzo Zuccotti
Department of Pediatrics, Vittore Buzzi Children’s Hospital-University of Milan, 20154 Milan, Italy
Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy
Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, “Aldo Moro” University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy
KidZ Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
Author to whom correspondence should be addressed.
Nutrients 2019, 11(6), 1399;
Submission received: 25 May 2019 / Revised: 14 June 2019 / Accepted: 17 June 2019 / Published: 21 June 2019
(This article belongs to the Special Issue Cow's Milk and Allergy)


Cow’s milk proteins cause allergic symptoms in 2% to 3% of all infants. In these individuals, the physiological mechanism of tolerance is broken with subsequent possible sensitization to antigens, which can lead eventually to allergic responses. The present review aims to provide an overview of different aspects of immune modulation by dietary intervention in cow’s milk allergy (CMA). It focuses on pathogenetic mechanisms of different CMA related disorders, e.g., gastroesophageal reflux and eosinophilic esophagitis, highlighting the role of dietary management on innate and adaptive immune systems. The traditional dietary management of CMA has greatly changed in the last years, moving from a passive approach, consisting of an elimination diet to relieve symptoms, to a “proactive” one, meaning the possibility to actively modulate the immune system. Thus, new insights into the role of hydrolysates and baked milk in immunomodulation are addressed here. Additionally, nutritional components, such as pre- and probiotics, may target the immune system via microbiota, offering a possible road map for new CMA prevention and treatment strategies.

1. Introduction

Cow’s milk allergy (CMA) is one of the most common food allergies in early childhood, with an estimated prevalence of 2% to 3% [1]. A growing body of evidence suggests a close relationship between immunoinflammation and gastrointestinal (GI) motility triggered by dietary antigens [2]. Cow’s milk (CM) free diets and in particular extensive hydrolyzed formulas may reduce gastrointestinal (GI) symptoms due to both immune mechanisms and motility alterations, such as reduced gastric emptying time. Food allergy plays a central role in driving the allergic reaction in eosinophilic esophagitis (EoE) and cow’s milk is the single most common food allergen causing esophageal inflammation [3].
Dietary elimination therapy is thought to target the adaptive immune system, by suppressing antigen-driven T-cell response. Moreover, the role of milk lipids as potential triggers of milk-induced inflammation in EoE is emerging. These findings provide new insights into EoE pathogenetic mechanisms that might change the paradigm of allergy, as a protein antigen-driven response. In the last decade, much has changed in the treatment of food allergy, switching from a passive approach, consisting of a restrictive diet to relieve symptoms, to a “proactive” one, meaning the possibility to actively modulate the immune system.
Protein hydrolysates have been recognized as a potent source of bioactive peptides [4]. They may act locally, e.g., in the gut, by modulating the intestinal microbiota, thereby playing a role in inducing oral tolerance to milk proteins. Additionally, the role of baked milk as a possible form of oral immunotherapy has emerged [5,6]. Maintaining tolerance requires complex interactions between non-immune cells and cells that belong to the gut-associated lymphoid tissue (GALT). Regulatory T cells (Treg) play a crucial role in tolerance. Although different subtypes of Tregs have been identified, the pivotal roles of Foxp3+ in oral tolerance are not completely understood. Gut microbes induce the activation of Tregs, while the same cells are depleted in germ-free mice [7]. Gut microbiota dysbiosis induces alterations in gut function resulting in aberrant Th2 responses towards allergic, rather than tolerogenic response [8]. Therefore, the possibility to actively immunomodulate the immune system targeting microbiota by nutritional factors, e.g., prebiotics and probiotics, represents a novel research strategy. The present review aims to give an overview of the different aspects of immunomodulation by dietary intervention in CMA, based on the most recent evidence.

2. Cow’s Milk Allergy and Allergic Dysmotility: A Pleiomorphic Disorder

CMA affects many organs with immediate and delayed reactions [9]. According to the Hill and Hosking classification, CMA may manifest in three different ways: (1) The IgE-sensitized group showing immediate cutaneous reactions and anaphylaxis; (2) the non-IgE-sensitized group with gastrointestinal (GI) symptoms, developing within hours after ingesting moderate amounts of CM; and (3) the group with GI disturbances with or without respiratory symptoms and/or eczema/urticaria, occurring after several hours or days [10].
Allergies may involve the GI tract from mouth to rectum, and may be characterized by an acute (anaphylaxis) or delayed onset [9], the latter including eosinophilic gastroenteropathy, allergic proctocolitis, food protein-induced enterocolitis syndrome, and enteropathy [11]. Allergic dysmotility encompasses different entities, including gastroesophageal reflux disease (GERD), dyspepsia, and constipation, where digestive motility is altered by the neuro-immune-muscle inflammatory interaction triggered by the cow’s milk proteins in predisposed individuals [9,11]. Up to half of the cases of GERD in infants younger than 1 year have been related to CMA based on clinical presentation and improvement on CM [12,13,14]. However, many symptoms, such as weight loss, failure to thrive, food-refusal, irritability, excessive crying, regurgitation, vomiting, anemia, wheezing, and sleep disturbances, may be expressions of both entities [13,14]. By contrast, multiple organ involvement, mucous or bloody stools, an increase in eosinophils blood count, atopic dermatitis, or recurrent bronchitis are more suggestive of CMA [13,14].
However, the reasons for clinical improvement after being started on a milk free diet may vary: The physiological resolution of symptoms over time, an improvement in gastric emptying due to the use of hydrolyzed proteins, or a placebo effect on parental anxiety.
The strongest evidence that intestinal allergic responses can modulate enteric motility originates from a series of studies in animal models. Cytokines production by T helper (Th) 2 cells, and recruitment and activation of either mast cells or eosinophils have been suggested as the major mechanisms potentially linking allergic responses and dysmotility [15]. A Th 2 polarized response determines the release of interleukin (IL)-4 and -13, cytokines that alter motility by upregulating transforming growth factor-beta, with spontaneous contractility of smooth muscle [15]. In a murine model of luminal sensitization, the allergen exposure induced a skew towards a Th2 response with tissue infiltration of IgE degranulating mast cells in the mucosa and mesenteric lymph nodes, causing enteropathy with loose stools and poor weight gain [16]. Moreover, mast cells and their mediators may cause sensorimotor dysfunction of the gut through interactions with the enteric nervous system [17,18,19].
An increase in mast cell density and number in close proximity to submucosal nerve endings has been demonstrated in children with functional dyspepsia and allergies [2]. In allergic children, milk allergen exposure induces rapid degranulation of gastric antral lamina propria mast cells and eosinophils and the release of mast cell tryptase, which interacts with proteinase-activated receptors that colocalize with gastric mucosal nerve fibers. Subsequent electrogastrographic myoelectrical abnormalities occur, determining atopy-related dyspeptic symptoms [2].
In the esophagus, animal studies have shown the degranulation of mast cells and the release of histamine when the mucosa was exposed and injured by acid [20] or when the stress-induced corticotrophin-releasing factor (CRF) signaling system [21,22] was involved. A rise in mast cell numbers and released cytokines has also been demonstrated in humans with non-erosive reflux disease and chest pain syndromes [23,24]. Mast cells play an important role in the esophageal inflammatory reaction and nociception by increasing vagal nociceptive C fibers’ excitability [25,26]. Proteinase activated receptors 2 (PAR2), a target receptor of mast cell derived tryptase, is expressed in epithelial cells, GI smooth muscle cells, and capsaicin-sensitive neurons and regulates GI mucosa barrier functioning and inflammation [27,28,29]. PAR2-mediated pathways have been demonstrated to be important in the pathogenesis of GERD-associated mucosal alterations, such as dilated intercellular spaces and a decrease of tight junction proteins [23,30].
The diagnosis of CMA in patients with GI symptoms is often challenging because of the delayed type of allergic reaction and the absence of specific diagnostic tests: Skin prick or serum specific IgE are usually negative, while atopy patch tests have shown conflicting data [31,32]. Hence, elimination diet followed by an oral open or double blind standardized challenge, in infants or older children is the recommended test to diagnose CMA [33,34]. In allergic patients, GI symptoms disappear in up to 2 to 4 weeks on a CM free diet and relapse when milk is reintroduced [33]. Extensive hydrolisate milk formulas are indicated as the first dietetic choice, whereas elemental formulas should be reserved for more severe cases or eosinophilic disorders [33,35]. A hypoallergenic diet has been proven effective in reducing mast cell mucosal infiltration, thus normalizing immune-nerve interactions and improving motor abnormalities [2,36]. At the same time, hydrolyzed proteins may be effective in these children due to accelerated gastric emptying [13,14]. In patients with persistent symptoms who are on a diet, esophageal pH-impedance may provide data on acid and non-acid reflux exposure and temporal reflux–symptoms association whereas esophagogastroduodenoscopy with esophageal and duodenal biopsies may reveal the presence and the type of esophagitis and/or enteropathy [13].

3. Eosinophilic Esophagitis: Insights on Pathogenetic Mechanisms and Dietary Immunomodulation

EoE is a chronic immune-mediated antigen-driven inflammatory disorder characterized by symptoms of esophageal dysfunction and histologic evidence of eosinophilic-predominant inflammation of the esophagus [37,38].
Clinical presentation varies according to age. In infants and younger children, the most common symptoms are food refusal, vomiting, irritability, and failure to thrive. Dysphagia, choking, and food impaction are the most common symptoms in school children and adolescents, as well as in adults [39,40].
Diagnostic criteria for EoE are: (a) Symptoms of esophageal dysfunction; (b) eosinophilic esofageal inflammation, ≥15 eosinophils (Eo)/per high power field (HPF); and (c) exclusion of other causes of esophageal eosinophilia [37,41].
EoE pathogenesis is closely related to atopy. About 70% of patients have a history of atopy, including asthma, IgE-mediated food allergy, allergic rhinitis, and atopic dermatitis. Similarly, about 2/3 of patients have at least one family member with an atopic condition [42]. Peripheral blood eosinophilia is observed in about 50% of patients, and elevated levels of IgE can be detected in 80% of patients. Moreover, up to 80% of patients have positive skin prick tests (SPTs) and/or specific IgE (sIgE) for food or aeroallergens.
Food allergy plays a central role in driving the allergic reaction in EoE, as demonstrated by clinical and histological remission on dietary restriction therapy and exacerbation after food reintroduction [43].
However, the lack of immediate symptoms after food ingestion, the low predictive value of SPTs or SIgE, and the poor response to anti-IgE therapy [44] disprove the hypothesis of a merely IgE- mediated food reaction. The pathogenesis of EoE is most likely a mixed IgE and non-IgE/cell mediated food reaction, in which Th2 cytokines, particularly thymic stromal lymphopoietin (TSLP), interleukin (IL)-4, IL5, IL13, and transforming growth factor-β (TGF-β), and eosinophilic chemokines (eotaxin 1-3/CCL11-CCL24-CCL26 and RANTES/CCL5) play a central role in eosinophilic recruitment, perpetuating local Th2-inflammation. Eosinophils cause tissue damage, remodeling, and fibrosis.
Antigens, primarily food ones, activate the innate and adaptive immune systems, priming the Th2 immune response [45,46].
The goal of therapy is to induce clinical and histological remission (defined as esophageal Eo < 15/HPF). Treatment strategies include drugs (e.g., proton pump inhibitors, corticosteroids) and elimination diets. These therapies both act on esophageal inflammation.
An avoidance diet is thought to target the adaptive immune system, by suppressing antigen-driven T-cell response; it requires elimination of food antigen/s, demonstration of remission, and subsequent sequential reintroduction of each single food in order to identify the causative agent [47,48,49].
Different elimination strategies are currently used in EoE: Elemental diet and empirical elimination diets, such as the six-food groups elimination diet (milk, wheat, soybean/legumes, egg, peanut/nuts, and fish/shellfish) (SFED), four-food elimination diet (milk, wheat, egg, legumes/soy) (FFED), or allergy testing-based food elimination diet (ATBD).
The efficacy of these different dietary treatments ranges from 90.8% for the elemental diet, to 72% for SFED, 55% for FFED, and 45.5% for ATBD [43,50].
After sequential food reintroduction, in the majority of patients (45–85%), one or two causative foods are identifiable. (2) Much evidence supports CM as a major trigger food for EoE. CM is the single most common food allergen causing esophageal inflammation. In both adults and children studies on empiric SFED-FFED or two-food elimination diet (TFED), CM was identified as the single trigger in 18% to 50% of adult patients [3,51,52] and from 30% up to 60% of pediatric patients, in prospective studies [3,52,53].
Moreover, CM elimination diet induced a significant reduction in the mean peak pre- and post-treatment eosinophil count in 68.2% of patients [54,55]. Sensitization to CM (serum sIgE and/or positive skin prick test) was detected in 45.9% of children with EoE, in a large cohort of European EoE children [42].
However, it is known that sIgE correlates poorly with food triggers. Furthermore, it has been observed that CM sIgE levels are paradoxically lower in responders to the CM elimination diet, than in non-responders [56]. These findings are in keeping with the evidence of a non-IgE-mediated reaction.
Nevertheless, even in patients with negative skin prick tests, sIgE to whey protein Bos d 4 (α-lactalbumin) and Bos d 5 (β-lactoglobulin) are frequently detectable by ImmunoCAP assay. Therefore, although IgE response is not the primary mechanism in EoE, Bos d 4 and Bos d 5, minor components of CM, can act as primary antigens for IgE response, triggering T cell-driven inflammation in EoE.
Another antibody isotype currently investigated in EoE is IgG4. IgG4 is an immunoglobulin involved in allergen tolerance and anti-inflammatory activity. High levels of serum and esophageal IgG4 have been found in active EoE in adults [57]. Recently, it has been demonstrated that levels of esophageal IgG4 in EoE patients correlate with the number of esophageal eosinophils, with basal zone hyperplasia, and with levels of IL4 to IL13, and especially IL10, providing evidence that IgG4 correlates with disease activity (i.e., eosinophils and basal zone hyperplasia) and Th 2 inflammation [58]. The highest titers of IgG4 in EoE are to CM and gluten. Levels of serum IgG4 to CM proteins (Bos d 4, Bos d 5 and casein, Bos d 8) are higher in active EoE than in controls. These data suggest a pathogenetic role for IgG4, especially to CM proteins, in EoE.
However, levels decrease on a CM elimination diet not only in subjects with histological remission, but also in subjects without remission, suggesting that IgG4 could be only an epiphenomenon in EoE [59].
Invariant natural killer T cells (iNKTs), a subset of T cells, play a key role in IgE-mediated CM allergy. They are activated by sphingolipids (SLs) rather than by protein antigens. Milk sphingomyelin (milk-SM) activate iNKTs, induce iNKTs’ proliferation, and promote Th2 response [60]. In children with IgE mediated food allergy, especially to CM milk, iNKTs are reduced. Children with active EoE have lower peripheral blood iNKTs with greater Th2 response to milk-SM compared to children with controlled EoE and controls. Esophageal iNKTs are higher in active EoE than in controlled EoE and healthy children. Low peripheral iNKTs could reflect recruitment on site of esophageal inflammation, suggesting a pathogenetic role of iNKTs in EoE [61].
These findings could explain why some foods are more able to trigger EoE than others, and provide new insights into EoE pathogenetic mechanisms. Milk lipids as potential triggers of milk-induced inflammation may change the paradigm of allergy, as a protein antigen-driven response.

4. Immune Modulation by Hydrolysate Proteins

Great consideration has recently been given to hydrolysate proteins. Their capacity to reduce allergic symptoms due to the lack of IgE binding epitopes is common knowledge [62]. Therefore, infant formulas containing extensively hydrolyzed proteins are tolerated by allergic infants and are recommended for the management of children with CMA symptoms [63,64].
Furthermore, hydrolysates have been demonstrated as capable of reducing the gut intestinal permeability [65] in ex vivo models. The improved barrier function may decrease the antigen uptake and the antigen contact with the intestinal immune cells in the lamina propria, which may lead to a reduction in allergic symptoms [66].
More recent evidence, however, suggests that hydrolyzed peptides also have an active role in modulating the immune system through different mechanisms both in children with CMA and in those at risk of developing CMA [67,68]
In vitro and ex vivo studies have described hydrolysates as having local and systemic effects on the immune system, including their ability to strengthen the epithelial barrier, via many immunomodulatory mechanisms, such as increasing the regulatory cytokines (e.g., IL-10) or decreasing the inflammatory markers, including cyclo-oxygenase 2 (COX-2), NF-kB, and IL-8, and also by the expression of genes encoding for tight junction proteins [65].
Protein hydrolysates act on the intestinal mesenteric lymph nodes, increasing the number of Treg cells, which are crucial in inducing tolerance [69]. These effects have been demonstrated in murine models analyzing both peptides derived from casein and whey proteins [70,71,72]. Besides enhancing the Treg number in the mesenteric lymphonodes, other effects on the local immune system have been described. In particular, hydrolysates from bovine milk seem to have an anti-inflammatory effect in vivo that is dependent on the protein source (casein or whey). These effects have been observed in animal models after inducing experimental colitis. While pro-inflammatory cytokines, IL-1beta, IL-17, TNF-alpha, and IFN, decreased, an increase in the regulatory cytokine, IL-10, and reduced macroscopical and microscopical damage of the colon mucosa was observed after administration of casein hydrolysate or casein glycomacropeptide [71,73,74]. Based on this and other experimental findings, feeding with a casein eHF is actually recommended as a first-line choice for the management of food protein induced enterocolitis [75].
Feeding with a partially hydrolyzed whey protein diet reduced allergic skin response in a cow’s milk allergy mouse model, by decreasing the levels of Th1, Th17, and enhancing regulatory T and B cells in Peyer plaques after whey challenge [76]. Interestingly, a sequenced peptide derived from whey has been demonstrated to reduce the whey antibody levels in animal models.
Protein hydrolysates also have an effect on the systemic immune system probably via small peptides that pass through the intestinal barrier and enter the systemic circulation. An increase in IL-10 producing regulatory B cells was observed after inducing oral tolerance by administration of intact casein in casein-allergic mice and in the spleen after whey hydrolysates’ administration, respectively [76,77].
Peptides can exert their immune modulatory effects via different mechanisms, among which the direct stimulation of the receptors on immune cells via Toll-like receptors (TLR) is one of the most important [78]. Other mechanisms have been described, including cells’ absorption via transporter or via endocytosis that leads to interactions with inflammatory signaling pathways or conversely to the inhibition of inflammatory signaling pathways [78] (Figure 1).
The majority of studies on the effects of immune modulation by hydrolyzed formula were conducted on ex vivo models; there are very few data regarding how to speed up an increase in tolerance in infants fed with hydrolyzed formulas. However, these studies mostly came from the same group of authors [79,80] and need confirmation before drawing firm conclusions.
The peptides with an immunomodulatory effect are mostly small in size (2 to 20 amino acids), although peptides with a molecular weight over 1000 daltons in whey and soy proteins hydrolysates also seem to have immunomodulatory properties [77,81]. While different protein hydrolysates seem able to directly modulate the local and systemic immune system, the final effect depends on the type of hydrolysate and on the protein source. Furthermore, only few immunomodulatory peptides have been identified up to now. Indeed, further research should be focused on identifying specific immunomodulatory peptides and investigating their immune effects in humans.

5. Baked Milk: A Possible Form of Oral Immunotherapy?

Most children with CMA can tolerate baked milk [82,83]. At baseline, children tolerant to baked milk differ from reactive children by having lower milk-specific, beta-lactoglobulin, and casein IgE concentrations [84] and a higher number of Treg cells [85] Although casein IgE levels have been shown to have the best accuracy in predicting the reactivity to a baked milk challenge [86], the test’s performance relies on the decided cut-off points, which, in turn, depend on the sensibility and specificity of the test. Indeed, on an individual basis, an oral food challenge with baked milk should be performed to identify baked milk tolerant subjects as no laboratory testing can predict patient tolerance to baked milk in a reliable and conclusive way.
Many cohort and retrospective studies have hypothesized that CMA resolution occurs more rapidly in cases of regular baked milk assumption [82,84].
However, since cow’s milk tolerance can spontaneously occur in the first years of life, studies without a control group could not explain whether the faster tolerance observed is due to real immune modulation via a baked product, or by a milder phenotype of those patients [82,87,88].
A recent systematic review [88], considering only published observational studies, found weak evidence that the ingestion of baked hens’ eggs or cow’s milk results in an acceleration of tolerance achievement. However, very recently, a controlled randomized clinical trial showed that introducing baked milk in cow’s milk protein allergic patients accelerates the tolerance to fresh milk [5].
It is well known that oral immunotherapy (OIT) plays an immunological role by modulation of humoral and cell immunity. Humoral changes caused by OIT include a decrease in IgE levels and a rise in IgG levels, especially IgG4, which have a protective role on allergic reactions by blocking IgE-mediated basophil and mast cell activation. T cell response modifications include a reduction of Th2 cell line and Th2 cytokines’ expression [89,90]. A study from Goldberg et al. [91] showed that baked-milk reactive patients, who underwent baked milk OIT and reached maintenance dose, present a decrease in IgE reactivity to casein and alpha-lactalbumin. Similar to what happens during OIT [6], studies on the immune profile have suggested that after regular ingestion of baked milk products in baked mild tolerant children, casein IgG4 levels increase [82,84], while casein and beta lactoglobulin-specific IgE levels and casein IgE/IgG4 and beta lactoglobulin IgE/IgG4 ratios decrease [82].
All these findings together suggest that the ingestion of baked milk products could drive a change in immune patterns, speeding up milk tolerance. However, further randomized studies are warranted to confirm this hypothesis.
Besides, the opportunity to reduce the child’s dietary and label-related restrictions has been demonstrated to reduce the stress levels with a beneficial effect on the quality of life of food-allergic children and their families [92,93].

6. Gut Microbiota in Perinatal Period and Its Relationship with Immune Function and Allergy Development

Gut microbiota are influenced by several factors occurring during pregnancy and after birth [94,95].
Several studies have evaluated the relationship between bifidobacterial colonization and the development of allergic diseases, including cow’s milk allergy [96,97,98].
Oral feeding determines the major modifications in the composition of intestinal microbiota. Breast milk contains important substances influencing the development of a newborn’s immune system [99]. A recent study [100] suggests that lactoferrin passes throughout breast milk to the intestine of the newborn, promoting the growth of bifidobacteria, which in turn contributes to the regulation of postnatal intestinal development [101].
Human milk contains mainly Lactobacilli and Bifidobacteria with an estimated number of ingested bacteria of 1 × 105 to 1 × 107 per 800 mL of milk consumed daily [102]. These bacteria stimulate endogenous production of secretory IgA [103], activation of T regulatory cells [104], and anti-inflammation response [105,106]. Gut microbiota establishment in early life is crucial for the success of oral tolerance, mediated by Foxp3þ and Treg, known to inhibit immune activation [107,108]. Germ free mice showed a Th2-skewed response [109]. An early exposure to pro-and/or prebiotics during the prenatal period and in early life might be beneficial in preventing Th2- mediated allergic disease, including food allergy [110].

7. Prebiotics and CMA

An increasing body of evidence shows that the gut microbiota contributes to the maturation of the immune system [111]. An altered patterns of early colonization, e.g., “dysbiosis,” predisposes people to allergic diseases. Prospective studies have demonstrated that a gut microbial imbalance due to reduced diversity in the early years of life is associated with an increased risk of developing food sensitization and atopic eczema [112,113,114]. Although the specific microbiota dysfunction in allergies remains unclear, both prebiotics and probiotics probably modulate immune development through a number of different pathways that can be modified by host and environmental factors. Prebiotic carbohydrates are a major substrate for bacterial growth, and stimulate selectively the growth and/or activity of beneficial species of the gut microbiota. The bifidogenic effect of human milk (a rich source of oligosaccharides) and of certain prebiotics (i.e., fructo- and galacto-oligosaccharides) added to infant milk formulas has long been reported [115,116].
Human milk oligosaccharides (HMOs) may both reduce the adhesion of pathogens and act as metabolic substrates for select species, contributing to the shaping of the infant gut microbiota and modulating the immune system [117] and health of infants [118]. However, there are hundreds of different HMOs, with specific properties and functions [97]. Up to now, only a small number of HMOs have been synthetized and added to infant formula, showing beneficial results [97]. According to a recent study, infants fed with human milk containing low Lacto-N-fucopentaose III (LNFP) concentrations were more likely to become affected by CMA compared to infants receiving high LNFP III-containing milk (odds ratio 6.7, 95% CI 2.0–22) [119].
A systematic review [120] on HMOs reported a protective effect against CMA by 18 months of age.
A beneficial effect of a special mixture of prebiotics (short-chain galacto- and long chain fructo-oligosaccharides) on the development of atopic dermatitis in a high risk population of infants was shown for the first time in 2006 [116].
Fewer infants in the intervention group (hydrolyzed protein formula + prebiotic mixture) developed atopic dermatitis compared to infants in the control group (hydrolyzed protein formula + maltodextrine) (9.8%; 95 CI 5.4–17.1% vs. 23.1%; 95 CI 16.0%–32.1%) In the intervention group, a significantly higher number of faecal bifidobacteria was detected compared to the controls [116]. A systematic review and meta-analysis found no effect on the onset of asthma whilst it did find a significant reduction in eczema (four studies, 1218 infants; risk ratio (RR) 0.68, 95% CI 0.48–0.97, with a number needed to treat 25 (95% CI 14 to >100)) [121]. Conversely, a more recent systematic review reported no difference in eczema (RR: 0.57, 95% CI: 0.30e1.08). Only one study evaluated the risk of food allergy and found a reduced risk (RR: 0.28, 95% CI 0.08e1.00) in prebiotic-treated infants [122].
A very recent study [111] assessed the effect of a partially hydrolyzed protein formula supplemented with non-digestible oligosaccharides on the prevention of eczema in 138 infants at high risk of allergy. Infants receiving the prebiotic formula had a fecal microbial composition, metabolites, and pH closer to that of breast-fed infants than that of infants receiving standard cow’s milk formula. Infants with eczema by 18 months showed decreased acquisition of Eubacterium and Anaerostipes species with increased lactate and reduced butyrate levels [111].
A similar effect was also shown in non-at-risk infants [123]: In total, 414 infants received an intact protein formula containing a specific mixture of neutral oligosaccharides and pectin-derived acidic oligosaccharides compared to 416 infants fed with a control formula without oligosaccharides. Up to the first year of life, atopic dermatitis occurred in a significantly higher number of infants from the control group (9.7%) than the prebiotic group (5.7%) [123]. The addition of lactose to an extensively hydrolyzed formula significantly increased the total fecal counts of Bifidobacteria and lactic acid bacteria, and decreased that of Bacteroides/Clostridia.s. Moreover, lactose significantly increased the concentration of total short-chain fatty acids, especially acetic and butyric acids, as demonstrated by the metabolomic analysis [124].
A recent multicenter double-blind randomized controlled trial [125] investigated the effects of an amino acid-based formula (AAF), including fructo-oligosaccharides, and the probiotic strain, Bifidobacterium breve M-16V, in 35 infants with suspected non-IgE-mediated CMA. After 8 weeks of diet, the median percentage of Bifidobacteria was significantly (p < 0.001) higher in the test group than in the 36 control subjects fed non-supplemented AAF (35.4% vs. 9.7%), whereas Eubacterium rectale/Clostridium coccoides group in feces was lower (9.5% vs. 24.2%) and similar to that detected in breastfed infants (55% and 6.5%, respectively).
A subsequent double-blind randomized controlled multicenter trial with the same study groups and formulas confirmed the same fecal microbiota changes at 26 weeks [126]. Safety parameters were similar between groups.
Data from animal models have shown that in whey-sensitized mice, dietary supplementation with short chain galacto-oligosaccharides, long chain fructo-olgosaccharides, pectin-derived acidic oligosaccharides, and/or mixtures of the above prebiotics effectively reduced allergic symptoms but differentially affected mucosal immune activation. In whey-sensitized mice, mixtures of prebiotics increased the number of Foxp3+ cells in the proximal small intestine compared to sham-sensitized mice [127]. The increased expression of Th2 and Th17 mRNA markers in the small intestine of whey-sensitized mice was prevented by the mixture of galacto and fructo-oligosaccharides. Adding pectin-derived acidic oligosaccharides to this mixture enhanced Tbet (Th1), IL-10, and TGF-β mRNA expression, which was maintained in the distal small intestine and/or colon [127]. Interestingly, a more recent study [128] showed that co-administration of oligosaccharides and partially hydrolyzed whey protein can induce immunological tolerance in mice orally sensitized with whey and/or cholera toxin on day 35, particularly if the intake was on a daily basis. The oligosaccharide composition seems to influence the tolerance inducing mechanisms and was associated with the decrease of Lactobacillus species, being replaced by Bacteroidales family S24-7 members and with the relative abundance of Prevotella [128].
In 2011, the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Committee on Nutrition concluded that there was insufficient evidence to recommend the use of prebiotics in infant formula to prevent atopic disease [129].
Conversely, based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, in 2016, the World Allergy Organization guideline panel suggested the use of prebiotic supplementation in not-exclusively breastfed infants; however, both recommendations were based on a very low certainty of evidence [122].
At present, despite some promising results mainly related to the effect of specific prebiotics on the gut microbiota, clinical evidence of the beneficial effect of prebiotics in CMA is still inconclusive [128].

8. Probiotics and CM

Several studies have shown that probiotic supplementation given to women during pregnancy and lactation can modulate the microbial milk composition and immunity-modulating molecules, with health benefits ranging from gastrointestinal symptoms to allergies, transferred to the newborn [130]. Administration to mothers of a probiotic mixture (sold in continental Europe and the USA as Vivomixx® and Visbiome®-, -Danisco-Dupont, WI, USA,) resulted in an increase of Lactobacilli and Bifidobacteria in both colostrum and mature milk [131] in the “probiotic group” with respect to the “placebo group”, and in breast milk concentrations of secretory IgA and TGF-β and IL-10 (anti-inflammatory and immunomodulatory cytokines) [132]. This increasing gut maturation influences a newborn’s IgA production and seems to improve gastrointestinal functional symptoms in infants [132]. TGF-β ingested through breast milk restrains inflammatory responses in intestinal epithelial cells and T cells and exerts a modulation on the immune tolerance towards dietary antigens and indigenous intestinal microbes by induction of Treg cells [132]. It also increases the IgA production in newborns, improving the intestinal barrier function [133].
Maternal probiotic supplementation during pregnancy and breastfeeding seems to prevent atopic eczema in children [130]. The results of the main studies (RCT) are shown in Table 1 [134,135,136,137,138,139,140,141] (Table 1).
Further studies are requested in order to confirm the possibility of preventing other allergic disorders with perinatal probiotic administration.
The World Allergy Organization (WAO) [142] recommends the use of probiotics in pregnant and breastfeeding women and in non-exclusively breastfed infants at high risk of allergic disease. On the other hand, the Academy of Allergy and Clinical Immunology [143] and European Society for Paediatric Gastroenterology, Hepatology, and Nutrition [129] do not recommend the use of probiotics and/or prebiotics for the prevention of allergic diseases. However, the WAO guideline panel recognizes that the recommendations of both probiotics and prebiotics are conditional and based on very low quality evidence.
In terms of the therapeutic property of probiotics, it has been demonstrated [144] that in infants with proctocolitis, the addition of Lactobacillus rhamnosus LGG to an extensively hydrolyzed cow’s milk protein formula determines a greater decrease in fecal calprotectin [145] and a reduction in the number of infants with a persistence of occult blood in stools after 1 month. LGG could enhance the intestinal mucosa’s barrier function and participate in the degradation of protein antigens, compete with pathogenic bacteria, and promote early immune system maturation towards non-allergy. A recent systematic review considered a randomized trial, involving 895 pediatric patients with CMA. The primary outcome of interest was relief of symptoms in terms of a reduction of the severity of atopic dermatitis (measured by the SCORing Atopic Dermatitis (SCORAD) index). Overall, a decrease of the SCORAD index was shown in subjects given probiotics, but the results were imprecise and do not permit firm conclusions to be drawn [146].
The results of Randomized Controlled Trials (RCT) on probiotics use in CMA treatment are shown in Table 2 (Table 2).
Great interest has recently arisen regarding the possible role of probiotics administration in fasting tolerance. Despite some evidence that a specific strain, such as Lactobacillus rhamnosus, LGG administration may induce tolerance among infants with CMA with a long-lasting effect [147]. Although, no general conclusions can be drawn, due to inconclusive evidence and imprecise results [146]. Further studies are required to investigate the effects of pre- and postnatal probiotic supplementation on the development of systemic and mucosal immunity. Similarly, the most effective strains, dosages, or optimal duration of treatment still need to be defined.
The use of probiotics is in general safe during pregnancy and in newborns (see Table 1). Kuitunen et al. [153] reported that newborns supplemented with probiotics before and after birth had significantly lower hemoglobin levels compared to the placebo group at six months of life. This effect was considered to be transient
Without proper identification of the strains the clinical evidence regarding one product could not be transferred from one product to another. This is the reason why the limiting of information to probiotic genera/species is not the best choice [154]. Without consideration of current regulatory and commercial loopholes, assessing harm will be difficult for researchers, physicians, and patients. More stringent regulations mandating full disclosure of the probiotic microorganisms at the strain level and the origin of the product and manufacturing changes are a prerequisite for proper safety and efficacy reporting [155].

9. Conclusions

Much has changed in recent years in food allergy management, moving from a one-size approach to a personalized one, associated with the specific food allergy phenotype. While different protein hydrolysates seem able to modulate the immune system, the few in vivo data, although promising, do not allow us to draw conclusions on their effect on tolerance achievement. Furthermore, the paucity and heterogeneity among the studies currently limit one’s ability to compare the results and to recommend the routine use of prebiotics and probiotics for prevention and treatment of CMA.

Author Contributions

Conceptualization, E.D. and G.Z.; Methodology, E.D., S.S., M.A. and Y.V.; Supervision, Y.V. and G.Z.; Writing—original draft, E.D., S.S., E.P., M.U.A.S., C.M., L.P. and M.E.B.; Writing—review and editing, E.D., S.S., M.U.A.S., L.P., and M.E.B.


This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interests related to this paper.


  1. Sicherer, S.H. Epidemiology of food allergy. J. Allergy Clin. Immunol. 2011, 127, 594–602. [Google Scholar] [CrossRef] [PubMed]
  2. Schappi, M.G.; Borrelli, O. Mast cell-nerve interactions in children with functional dyspepsia. J. Pediatr. Gastroenterol. Nutr. 2008, 47, 472–480. [Google Scholar] [CrossRef] [PubMed]
  3. Molina-Infante, J.; Arias, A. Four-food group elimination diet for adult eosinophilic esophagitis: A prospective multicenter study. J. Allergy Clin. Immunol. 2014, 134, 1093–1099.e1. [Google Scholar] [CrossRef] [PubMed]
  4. Bougle, D.; Bouhallab, S. Dietary bioactive peptides: Human studies. Crit. Rev. Food Sci. Nutr. 2017, 57, 335–343. [Google Scholar] [CrossRef] [PubMed]
  5. Esmaeilzadeh, H.; Alyasin, S. The effect of baked milk on accelerating unheated cow’s milk tolerance: A control randomized clinical trial. Pediatr. Allergy Immunol. 2018, 29, 747–753. [Google Scholar] [CrossRef]
  6. Huang, F.; Nowak-Wegrzyn, A. Extensively heated milk and egg as oral immunotherapy. Curr. Opin. Allergy Clin. Immunol. 2012, 12, 283–292. [Google Scholar] [CrossRef] [Green Version]
  7. Berni Canani, R.; Gilbert, J.A. The role of the commensal microbiota in the regulation of tolerance to dietary allergens. Curr. Opin. Allergy Clin. Immunol. 2015, 15, 243–249. [Google Scholar] [CrossRef] [Green Version]
  8. Plunkett, C.H.; Nagler, C.R. The Influence of the Microbiome on Allergic Sensitization to Food. J. Immunol. 2017, 198, 581–589. [Google Scholar] [CrossRef]
  9. Dupont, C. Diagnosis of cow’s milk allergy in children: Determining the gold standard? Expert Rev. Clin. Immunol. 2014, 10, 257–267. [Google Scholar] [CrossRef]
  10. Hill, D.J.; Hosking, C.S. The cow milk allergy complex: Overlapping disease profiles in infancy. Eur. J. Clin. Nutr. 1995, 49 (Suppl. 1), S1–S12. [Google Scholar]
  11. du Toit, G.; Meyer, R. Identifying and managing cow’s milk protein allergy. Arch. Dis. Child. Educ. Pract. Ed. 2010, 95, 134–144. [Google Scholar] [CrossRef] [PubMed]
  12. Heine, R.G. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr. Opin. Allergy Clin. Immunol. 2006, 6, 220–225. [Google Scholar] [CrossRef] [PubMed]
  13. Rosen, R.; Vandenplas, Y. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J. Pediatr. Gastroenterol. Nutr. 2018, 66, 516–554. [Google Scholar] [CrossRef] [PubMed]
  14. Salvatore, S.; Vandenplas, Y. Gastroesophageal reflux and cow milk allergy: Is there a link? Pediatrics 2002, 110, 972–984. [Google Scholar] [CrossRef] [PubMed]
  15. Murch, S. Allergy and intestinal dysmotility—Evidence of genuine causal linkage? Curr. Opin. Gastroenterol. 2006, 22, 664–668. [Google Scholar] [CrossRef] [PubMed]
  16. Nakajima-Adachi, H.; Ebihara, A. Food antigen causes TH2-dependent enteropathy followed by tissue repair in T-cell receptor transgenic mice. J. Allergy Clin. Immunol. 2006, 117, 1125–1132. [Google Scholar] [CrossRef] [PubMed]
  17. Barbara, G.; Stanghellini, V. Functional gastrointestinal disorders and mast cells: Implications for therapy. Neurogastroenterol. Motil. 2006, 18, 6–17. [Google Scholar] [CrossRef]
  18. Jakate, S.; Demeo, M. Mastocytic enterocolitis: Increased mucosal mast cells in chronic intractable diarrhea. Arch. Pathol. Lab. Med. 2006, 130, 362–367. [Google Scholar]
  19. Ramsay, D.B.; Stephen, S. Mast cells in gastrointestinal disease. Gastroenterol. Hepatol. 2010, 6, 772–777. [Google Scholar]
  20. Feldman, M.J.; Morris, G.P. Mast cells mediate acid-induced augmentation of opossum esophageal blood flow via histamine and nitric oxide. Gastroenterology 1996, 110, 121–128. [Google Scholar] [CrossRef]
  21. Wu, S.V.; Yuan, P.Q. Identification and characterization of multiple corticotropin-releasing factor type 2 receptor isoforms in the rat esophagus. Endocrinology 2007, 148, 1675–1687. [Google Scholar] [CrossRef] [PubMed]
  22. Zhong, C.J.; Wang, K. Mast cell activation is involved in stress-induced epithelial barrier dysfunction in the esophagus. J. Dig. Dis. 2015, 16, 186–196. [Google Scholar] [CrossRef] [PubMed]
  23. Yu, Y.; Ding, X. Alterations of Mast Cells in the Esophageal Mucosa of the Patients with Non-Erosive Reflux Disease. Gastroenterol. Res. 2011, 4, 70–75. [Google Scholar] [CrossRef] [PubMed]
  24. Zhong, C.; Liu, K. Developing a diagnostic understanding of GERD phenotypes through the analysis of levels of mucosal injury, immune activation, and psychological comorbidity. Dis. Esophagus 2018, 31, doy039. [Google Scholar] [CrossRef] [PubMed]
  25. Yu, S.; Gao, G. TRPA1 in mast cell activation-induced long-lasting mechanical hypersensitivity of vagal afferent C-fibers in guinea pig esophagus. Am. J. Physiol. Gastrointest. Liver Physiol. 2009, 297, G34–G42. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  26. Yu, S.; Kollarik, M. Mast cell-mediated long-lasting increases in excitability of vagal C fibers in guinea pig esophagus. Am. J. Physiol. Gastrointest. Liver Physiol. 2007, 293, G850–G856. [Google Scholar] [CrossRef]
  27. Cenac, N.; Chin, A.C. PAR2 activation alters colonic paracellular permeability in mice via IFN-gamma-dependent and -independent pathways. J. Physiol. 2004, 558, 913–925. [Google Scholar] [CrossRef]
  28. Itoh, Y.; Sendo, T. Physiology and pathophysiology of proteinase-activated receptors (PARs): Role of tryptase/PAR-2 in vascular endothelial barrier function. J. Pharmacol. Sci. 2005, 97, 14–19. [Google Scholar] [CrossRef]
  29. Liu, H.; Miller, D.V. Proteinase-activated receptor-2 activation evokes oesophageal longitudinal smooth muscle contraction via a capsaicin-sensitive and neurokinin-2 receptor-dependent pathway. Neurogastroenterol. Motil. 2010, 22, 210–216, e67. [Google Scholar] [CrossRef]
  30. Kandulski, A.; Wex, T. Proteinase-activated receptor-2 in the pathogenesis of gastroesophageal reflux disease. Am. J. Gastroenterol. 2010, 105, 1934–1943. [Google Scholar] [CrossRef]
  31. De Boissieu, D.; Waguet, J.C. The atopy patch tests for detection of cow’s milk allergy with digestive symptoms. J. Pediatr. 2003, 142, 203–205. [Google Scholar] [CrossRef] [PubMed]
  32. Majamaa, H.; Moisio, P. Cow’s milk allergy: Diagnostic accuracy of skin prick and patch tests and specific IgE. Allergy 1999, 54, 346–351. [Google Scholar] [CrossRef] [PubMed]
  33. Koletzko, S.; Niggemann, B. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J. Pediatr. Gastroenterol. Nutr. 2012, 55, 221–229. [Google Scholar] [CrossRef] [PubMed]
  34. Sampson, H.A.; Gerth van Wijk, R. Standardizing double-blind, placebo-controlled oral food challenges: American Academy of Allergy, Asthma & Immunology-European Academy of Allergy and Clinical Immunology PRACTALL consensus report. J. Allergy Clin. Immunol. 2012, 130, 1260–1274. [Google Scholar] [PubMed]
  35. Giovannini, M.; D’Auria, E. Nutritional management and follow up of infants and children with food allergy: Italian Society of Pediatric Nutrition/Italian Society of Pediatric Allergy and Immunology Task Force Position Statement. Ital. J. Pediatr. 2014, 40, 1. [Google Scholar] [CrossRef]
  36. Borrelli, O.; Barbara, G. Neuroimmune interaction and anorectal motility in children with food allergy-related chronic constipation. Am. J. Gastroenterol. 2009, 104, 454–463. [Google Scholar] [CrossRef]
  37. Lucendo, A.J.; Molina-Infante, J. Guidelines on eosinophilic esophagitis: Evidence-based statements and recommendations for diagnosis and management in children and adults. United Eur. Gastroenterol. J. 2017, 5, 335–358. [Google Scholar] [CrossRef]
  38. Papadopoulou, A.; Koletzko, S. Management guidelines of eosinophilic esophagitis in childhood. J. Pediatr. Gastroenterol. Nutr. 2014, 58, 107–118. [Google Scholar] [CrossRef]
  39. Miehlke, S. Clinical features of eosinophilic esophagitis. Dig. Dis. 2014, 32, 61–67. [Google Scholar] [CrossRef]
  40. Papadopoulou, A.; Dias, J.A. Eosinophilic esophagitis: An emerging disease in childhood—Review of diagnostic and management strategies. Front. Pediatr. 2014, 2, 129. [Google Scholar] [CrossRef]
  41. Dellon, E.S.; Gonsalves, N. ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Am. J. Gastroenterol. 2013, 108, 679–692. [Google Scholar] [CrossRef] [PubMed]
  42. Hoofien, A.; Dias, J.A. Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER). J. Pediatr. Gastroenterol. Nutr. 2019, 68, 552–558. [Google Scholar] [CrossRef] [PubMed]
  43. Arias, A.; Gonzalez-Cervera, J. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: A systematic review and meta-analysis. Gastroenterology 2014, 146, 1639–1648. [Google Scholar] [CrossRef] [PubMed]
  44. Loizou, D.; Enav, B. A pilot study of omalizumab in eosinophilic esophagitis. PLoS ONE 2015, 10, e0113483. [Google Scholar] [CrossRef] [PubMed]
  45. Aceves, S.S.; Chen, D. Mast cells infiltrate the esophageal smooth muscle in patients with eosinophilic esophagitis, express TGF-beta1, and increase esophageal smooth muscle contraction. J. Allergy Clin. Immunol. 2010, 126, 1198–1204.e4. [Google Scholar] [CrossRef] [PubMed]
  46. Leung, J.; Beukema, K.R. Allergic mechanisms of Eosinophilic oesophagitis. Best Pract. Res. Clin. Gastroenterol. 2015, 29, 709–720. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  47. Kagalwalla, A.F.; Sentongo, T.A. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis. Clin. Gastroenterol. Hepatol. 2006, 4, 1097–1102. [Google Scholar] [CrossRef] [PubMed]
  48. Liacouras, C.A.; Spergel, J.M. Eosinophilic esophagitis: A 10-year experience in 381 children. Clin. Gastroenterol. Hepatol. 2005, 3, 1198–1206. [Google Scholar] [CrossRef]
  49. Spergel, J.M.; Andrews, T. Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests. Ann. Allergy Asthma Immunol. 2005, 95, 336–343. [Google Scholar] [CrossRef]
  50. Gomez Torrijos, E.; Gonzalez-Mendiola, R. Eosinophilic Esophagitis: Review and Update. Front. Med. (Lausanne) 2018, 5, 247. [Google Scholar] [CrossRef]
  51. Gonsalves, N.; Yang, G.Y. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 2012, 142, 1451–1459.e1. [Google Scholar] [CrossRef] [PubMed]
  52. Molina-Infante, J.; Arias, A. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study. J. Allergy Clin. Immunol. 2018, 141, 1365–1372. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  53. Kagalwalla, A.F.; Wechsler, J.B. Efficacy of a 4-Food Elimination Diet for Children with Eosinophilic Esophagitis. Clin. Gastroenterol. Hepatol. 2017, 15, 1698–1707.e7. [Google Scholar] [CrossRef] [PubMed]
  54. Kagalwalla, A.F.; Amsden, K. Cow’s milk elimination: A novel dietary approach to treat eosinophilic esophagitis. J. Pediatr. Gastroenterol. Nutr. 2012, 55, 711–716. [Google Scholar] [CrossRef] [PubMed]
  55. Kruszewski, P.G.; Russo, J.M. Prospective, comparative effectiveness trial of cow’s milk elimination and swallowed fluticasone for pediatric eosinophilic esophagitis. Dis. Esophagus 2016, 29, 377–384. [Google Scholar] [CrossRef] [PubMed]
  56. Erwin, E.A.; Tripathi, A. IgE Antibody Detection and Component Analysis in Patients with Eosinophilic Esophagitis. J. Allergy Clin. Immunol. Pract. 2015, 3, 896–904.e3. [Google Scholar] [CrossRef] [Green Version]
  57. Clayton, F.; Fang, J.C. Eosinophilic esophagitis in adults is associated with IgG4 and not mediated by IgE. Gastroenterology 2014, 147, 602–609. [Google Scholar] [CrossRef] [PubMed]
  58. Rosenberg, C.E.; Mingler, M.K. Esophageal IgG4 levels correlate with histopathologic and transcriptomic features in eosinophilic esophagitis. Allergy 2018, 73, 1892–1901. [Google Scholar] [CrossRef]
  59. Schuyler, A.J.; Wilson, J.M. Specific IgG4 antibodies to cow’s milk proteins in pediatric patients with eosinophilic esophagitis. J. Allergy Clin. Immunol. 2018, 142, 139–148.e12. [Google Scholar] [CrossRef]
  60. Jyonouchi, S.; Abraham, V. Invariant natural killer T cells from children with versus without food allergy exhibit differential responsiveness to milk-derived sphingomyelin. J. Allergy Clin. Immunol. 2011, 128, 102–109.e13. [Google Scholar] [CrossRef] [Green Version]
  61. Jyonouchi, S.; Smith, C.L. Invariant natural killer T cells in children with eosinophilic esophagitis. Clin. Exp. Allergy 2014, 44, 58–68. [Google Scholar] [CrossRef] [PubMed]
  62. Tanabe, S. Analysis of food allergen structures and development of foods for allergic patients. Biosci. Biotechnol. Biochem. 2008, 72, 649–659. [Google Scholar] [CrossRef] [PubMed]
  63. Kneepkens, C.M.; Meijer, Y. Clinical practice. Diagnosis and treatment of cow’s milk allergy. Eur. J. Pediatr. 2009, 168, 891–896. [Google Scholar] [CrossRef] [PubMed]
  64. Sicherer, S.H.; Sampson, H.A. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J. Allergy Clin. Immunol. 2018, 141, 41–58. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  65. Visser, J.T.; Lammers, K. Restoration of impaired intestinal barrier function by the hydrolysed casein diet contributes to the prevention of type 1 diabetes in the diabetes-prone BioBreeding rat. Diabetologia 2010, 53, 2621–2628. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  66. Korhonen, H.; Pihlanto, A. Food-derived bioactive peptides--opportunities for designing future foods. Curr. Pharm. Des. 2003, 9, 1297–1308. [Google Scholar] [CrossRef] [PubMed]
  67. Kiewiet, M.B.G.; Gros, M. Immunomodulating properties of protein hydrolysates for application in cow’s milk allergy. Pediatr. Allergy Immunol. 2015, 26, 206–217. [Google Scholar] [CrossRef]
  68. Wichers, H. Immunomodulation by food: Promising concept for mitigating allergic disease? Anal. Bioanal. Chem. 2009, 395, 37–45. [Google Scholar] [CrossRef]
  69. Sakaguchi, S.; Powrie, F. Emerging challenges in regulatory T cell function and biology. Science 2007, 317, 627–629. [Google Scholar] [CrossRef]
  70. Meulenbroek, L.A.; van Esch, B.C. Oral treatment with beta-lactoglobulin peptides prevents clinical symptoms in a mouse model for cow’s milk allergy. Pediatr. Allergy Immunol. 2013, 24, 656–664. [Google Scholar] [CrossRef]
  71. Ortega-Gonzalez, M.; Capitan-Canadas, F. Validation of bovine glycomacropeptide as an intestinal anti-inflammatory nutraceutical in the lymphocyte-transfer model of colitis. Br. J. Nutr. 2014, 111, 1202–1212. [Google Scholar] [CrossRef] [PubMed]
  72. van Esch, B.C.; Schouten, B. Oral tolerance induction by partially hydrolyzed whey protein in mice is associated with enhanced numbers of Foxp3+ regulatory T-cells in the mesenteric lymph nodes. Pediatr. Allergy Immunol. 2011, 22, 820–826. [Google Scholar] [CrossRef] [PubMed]
  73. Espeche Turbay, M.B.; de Moreno de LeBlanc, A. Beta-Casein hydrolysate generated by the cell envelope-associated proteinase of Lactobacillus delbrueckii ssp. lactis CRL 581 protects against trinitrobenzene sulfonic acid-induced colitis in mice. J. Dairy Sci. 2012, 95, 1108–1118. [Google Scholar] [CrossRef] [PubMed]
  74. Requena, P.; Daddaoua, A. Bovine glycomacropeptide induces cytokine production in human monocytes through the stimulation of the MAPK and the NF-kappaB signal transduction pathways. Br. J. Pharmacol. 2009, 157, 1232–1240. [Google Scholar] [CrossRef] [PubMed]
  75. Nowak-Wegrzyn, A.; Chehade, M. International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J. Allergy Clin. Immunol. 2017, 139, 1111–1126.e4. [Google Scholar]
  76. Kiewiet, M.B.G.; van Esch, B. Partially hydrolyzed whey proteins prevent clinical symptoms in a cow’s milk allergy mouse model and enhance regulatory T and B cell frequencies. Mol. Nutr. Food Res. 2017, 61, 1700340. [Google Scholar] [CrossRef] [PubMed]
  77. Kim, A.R.; Kim, H.S. Mesenteric IL-10-producing CD5+ regulatory B cells suppress cow’s milk casein-induced allergic responses in mice. Sci. Rep. 2016, 6, 19685. [Google Scholar] [CrossRef] [PubMed]
  78. Kiewiet, M.B.G.; Dekkers, R. Toll-like receptor mediated activation is possibly involved in immunoregulating properties of cow’s milk hydrolysates. PLoS ONE 2017, 12, e0178191. [Google Scholar] [CrossRef]
  79. Berni Canani, R.; Nocerino, R. Effect of Lactobacillus GG on tolerance acquisition in infants with cow’s milk allergy: A randomized trial. J. Allergy Clin. Immunol. 2012, 129, 580–582. [Google Scholar] [CrossRef]
  80. Berni Canani, R.; Nocerino, R. Formula selection for management of children with cow’s milk allergy influences the rate of acquisition of tolerance: A prospective multicenter study. J. Pediatr. 2013, 163, 771–777.e1. [Google Scholar] [CrossRef]
  81. Kiewiet, M.B.G.; Dekkers, R. Immunomodulating protein aggregates in soy and whey hydrolysates and their resistance to digestion in an in vitro infant gastrointestinal model: New insights in the mechanism of immunomodulatory hydrolysates. Food Funct. 2018, 9, 604–613. [Google Scholar] [CrossRef] [PubMed]
  82. Kim, J.S.; Nowak-Wegrzyn, A. Dietary baked milk accelerates the resolution of cow’s milk allergy in children. J. Allergy Clin. Immunol. 2011, 128, 125–131 e2. [Google Scholar] [CrossRef]
  83. Leonard, S.A.; Nowak-Wegrzyn, A.H. Baked Milk and Egg Diets for Milk and Egg Allergy Management. Immunol. Allergy Clin. North Am. 2016, 36, 147–159. [Google Scholar] [CrossRef] [PubMed]
  84. Nowak-Wegrzyn, A.; Bloom, K.A. Tolerance to extensively heated milk in children with cow’s milk allergy. J. Allergy Clin. Immunol. 2008, 122, 342–347. [Google Scholar] [CrossRef] [PubMed]
  85. Shreffler, W.G.; Wanich, N. Association of allergen-specific regulatory T cells with the onset of clinical tolerance to milk protein. J. Allergy Clin. Immunol. 2009, 123, 43–52.e7. [Google Scholar] [CrossRef]
  86. Caubet, J.C.; Nowak-Wegrzyn, A. Utility of casein-specific IgE levels in predicting reactivity to baked milk. J. Allergy Clin. Immunol. 2013, 131, 222–224. [Google Scholar] [CrossRef] [PubMed]
  87. Dang, T.D.; Peters, R.L. Debates in allergy medicine: Baked egg and milk do not accelerate tolerance to egg and milk. World Allergy Organ. J. 2016, 9, 2. [Google Scholar] [CrossRef]
  88. Lambert, R.; Grimshaw, K.E.C. Evidence that eating baked egg or milk influences egg or milk allergy resolution: A systematic review. Clin. Exp. Allergy 2017, 47, 829–837. [Google Scholar] [CrossRef]
  89. Tordesillas, L.; Berin, M.C. Immunology of Food Allergy. Immunity 2017, 47, 32–50. [Google Scholar] [CrossRef] [Green Version]
  90. Upton, J.; Nowak-Wegrzyn, A. The Impact of Baked Egg and Baked Milk Diets on IgE- and Non-IgE-Mediated Allergy. Clin. Rev. Allergy Immunol. 2018, 55, 118–138. [Google Scholar] [CrossRef]
  91. Goldberg, M.R.; Nachshon, L. Efficacy of baked milk oral immunotherapy in baked milk-reactive allergic patients. J. Allergy Clin. Immunol. 2015, 136, 1601–1606. [Google Scholar] [CrossRef] [PubMed]
  92. D’Auria, E.; Abrahams, M. Personalized Nutrition Approach in Food Allergy: Is It Prime Time Yet? Nutrients 2019, 11, 359. [Google Scholar] [CrossRef] [PubMed]
  93. Lee, E.; Mehr, S. Adherence to extensively heated egg and cow’s milk after successful oral food challenge. J. Allergy Clin. Immunol. Pract. 2015, 3, 125–127.e4. [Google Scholar] [CrossRef] [PubMed]
  94. Collado, M.C.; Rautava, S. Human gut colonisation may be initiated in utero by distinct microbial communities in the placenta and amniotic fluid. Sci. Rep. 2016, 6, 23129. [Google Scholar] [CrossRef] [PubMed]
  95. Pickard, J.M.; Zeng, M.Y. Gut microbiota: Role in pathogen colonization, immune responses, and inflammatory disease. Immunol. Rev. 2017, 279, 70–89. [Google Scholar] [CrossRef]
  96. Van Zwol, A.; Van Den Berg, A. Intestinal microbiota in allergic and nonallergic 1-year-old very low birth weight infants after neonatal glutamine supplementation. Acta Paediatr. 2010, 99, 1868–1874. [Google Scholar] [CrossRef] [PubMed]
  97. Vandenplas, Y. Prevention and Management of Cow’s Milk Allergy in Non-Exclusively Breastfed Infants. Nutrients 2017, 9, 731. [Google Scholar] [CrossRef]
  98. Wopereis, H.; Oozeer, R. The first thousand days—Intestinal microbiology of early life: Establishing a symbiosis. Pediatr. Allergy Immunol. 2014, 25, 428–438. [Google Scholar] [CrossRef]
  99. Pratico, G.; Capuani, G. Exploring human breast milk composition by NMR-based metabolomics. Nat. Prod. Res. 2014, 28, 95–101. [Google Scholar] [CrossRef]
  100. Mastromarino, P.; Capobianco, D. Correlation between lactoferrin and beneficial microbiota in breast milk and infant’s feces. Biometals 2014, 27, 1077–1086. [Google Scholar] [CrossRef]
  101. Buccigrossi, V.; de Marco, G. Lactoferrin induces concentration-dependent functional modulation of intestinal proliferation and differentiation. Pediatr. Res. 2007, 61, 410–414. [Google Scholar] [CrossRef] [PubMed]
  102. Donnet-Hughes, A.; Perez, P.F. Potential role of the intestinal microbiota of the mother in neonatal immune education. Proc. Nutr. Soc. 2010, 69, 407–415. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  103. Jost, T.; Lacroix, C. New insights in gut microbiota establishment in healthy breast fed neonates. PLoS ONE 2012, 7, e44595. [Google Scholar] [CrossRef] [PubMed]
  104. Schwartz, S.; Friedberg, I. A metagenomic study of diet-dependent interaction between gut microbiota and host in infants reveals differences in immune response. Genome Biol. 2012, 13, r32. [Google Scholar] [CrossRef] [PubMed]
  105. Campeotto, F.; Baldassarre, M. Fecal expression of human beta-defensin-2 following birth. Neonatology 2010, 98, 365–369. [Google Scholar] [CrossRef] [PubMed]
  106. Furuta, S.; Toyama, S. Disposition of polaprezinc (zinc L-carnosine complex) in rat gastrointestinal tract and effect of cimetidine on its adhesion to gastric tissues. J. Pharm. Pharmacol. 1995, 47, 632–636. [Google Scholar] [CrossRef]
  107. Berin, M.C.; Shreffler, W.G. Mechanisms Underlying Induction of Tolerance to Foods. Immunol. Allergy Clin. N. Am. 2016, 36, 87–102. [Google Scholar] [CrossRef]
  108. Weissler, K.A.; Caton, A.J. The role of T-cell receptor recognition of peptide:MHC complexes in the formation and activity of Foxp3(+) regulatory T cells. Immunol. Rev. 2014, 259, 11–22. [Google Scholar] [CrossRef]
  109. West, C.E.; Jenmalm, M.C. The gut microbiota and its role in the development of allergic disease: A wider perspective. Clin. Exp. Allergy 2015, 45, 43–53. [Google Scholar] [CrossRef]
  110. West, C.E.; Jenmalm, M.C. Probiotics for treatment and primary prevention of allergic diseases and asthma: Looking back and moving forward. Expert Rev. Clin. Immunol. 2016, 12, 625–639. [Google Scholar] [CrossRef]
  111. Wopereis, H.; Sim, K. Intestinal microbiota in infants at high risk for allergy: Effects of prebiotics and role in eczema development. J. Allergy Clin. Immunol. 2018, 141, 1334–1342.e5. [Google Scholar] [CrossRef] [PubMed]
  112. Abrahamsson, T.R.; Jakobsson, H.E. Low diversity of the gut microbiota in infants with atopic eczema. J. Allergy Clin. Immunol. 2012, 129, 434–440. [Google Scholar] [CrossRef] [PubMed]
  113. Azad, M.B.; Konya, T. Infant gut microbiota and food sensitization: Associations in the first year of life. Clin. Exp. Allergy 2015, 45, 632–643. [Google Scholar] [CrossRef] [PubMed]
  114. Ismail, I.H.; Oppedisano, F. Reduced gut microbial diversity in early life is associated with later development of eczema but not atopy in high-risk infants. Pediatr. Allergy Immunol. 2012, 23, 674–681. [Google Scholar] [CrossRef] [PubMed]
  115. Boehm, G.; Lidestri, M. Supplementation of a bovine milk formula with an oligosaccharide mixture increases counts of faecal bifidobacteria in preterm infants. Arch. Dis. Child. Fetal Neonatal Ed. 2002, 86, F178–F181. [Google Scholar] [CrossRef]
  116. Moro, G.; Arslanoglu, S. A mixture of prebiotic oligosaccharides reduces the incidence of atopic dermatitis during the first six months of age. Arch. Dis. Child. 2006, 91, 814–819. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  117. Alderete, T.L.; Autran, C. Associations between human milk oligosaccharides and infant body composition in the first 6 mo of life. Am. J. Clin. Nutr. 2015, 102, 1381–1388. [Google Scholar] [CrossRef]
  118. Bode, L.; Contractor, N. Overcoming the limited availability of human milk oligosaccharides: Challenges and opportunities for research and application. Nutr. Rev. 2016, 74, 635–644. [Google Scholar] [CrossRef]
  119. Seppo, A.E.; Autran, C.A. Human milk oligosaccharides and development of cow’s milk allergy in infants. J. Allergy Clin. Immunol. 2017, 139, 708–711.e5. [Google Scholar] [CrossRef]
  120. Doherty, A.M.; Lodge, C.J. Human Milk Oligosaccharides and Associations with Immune-Mediated Disease and Infection in Childhood: A Systematic Review. Front. Pediatr. 2018, 6, 91. [Google Scholar] [CrossRef]
  121. Osborn, D.A.; Sinn, J.K. Prebiotics in infants for prevention of allergy. Cochrane Database Syst. Rev. 2013, CD006474. [Google Scholar] [CrossRef] [PubMed]
  122. Cuello-Garcia, C.A.; Fiocchi, A. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Prebiotics. World Allergy Organ. J. 2016, 9, 10. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  123. Gruber, C.; van Stuijvenberg, M. Reduced occurrence of early atopic dermatitis because of immunoactive prebiotics among low-atopy-risk infants. J. Allergy Clin. Immunol. 2010, 126, 791–797. [Google Scholar] [CrossRef]
  124. Francavilla, R.; Calasso, M. Effect of lactose on gut microbiota and metabolome of infants with cow’s milk allergy. Pediatr. Allergy Immunol. 2012, 23, 420–427. [Google Scholar] [CrossRef] [PubMed]
  125. Candy, D.C.A.; Van Ampting, M.T.J. A synbiotic-containing amino-acid-based formula improves gut microbiota in non-IgE-mediated allergic infants. Pediatr. Res. 2018, 83, 677–686. [Google Scholar] [CrossRef]
  126. Fox, A.T.; Wopereis, H. A specific synbiotic-containing amino acid-based formula in dietary management of cow’s milk allergy: A randomized controlled trial. Clin. Transl. Allergy 2019, 9, 5. [Google Scholar] [CrossRef] [PubMed]
  127. Kerperien, J.; Jeurink, P.V. Non-digestible oligosaccharides modulate intestinal immune activation and suppress cow’s milk allergic symptoms. Pediatr. Allergy Immunol. 2014, 25, 747–754. [Google Scholar] [CrossRef]
  128. Kleinjans, L.; Veening-Griffioen, D.H. Mice co-administrated with partially hydrolysed whey proteins and prebiotic fibre mixtures show allergen-specific tolerance and a modulated gut microbiota. Benef. Microbes 2019, 10, 165–178. [Google Scholar] [CrossRef]
  129. Braegger, C.; Chmielewska, A. Supplementation of infant formula with probiotics and/or prebiotics: A systematic review and comment by the ESPGHAN committee on nutrition. J. Pediatr. Gastroenterol. Nutr. 2011, 52, 238–250. [Google Scholar] [CrossRef]
  130. Baldassarre, M.E.; Palladino, V. Rationale of Probiotic Supplementation during Pregnancy and Neonatal Period. Nutrients 2018, 10, 1693. [Google Scholar] [CrossRef]
  131. Mastromarino, P.; Capobianco, D. Administration of a multistrain probiotic product (VSL#3) to women in the perinatal period differentially affects breast milk beneficial microbiota in relation to mode of delivery. Pharmacol. Res. 2015, 95–96, 63–70. [Google Scholar]
  132. Baldassarre, M.E.; Di Mauro, A. Administration of a Multi-Strain Probiotic Product to Women in the Perinatal Period Differentially Affects the Breast Milk Cytokine Profile and May Have Beneficial Effects on Neonatal Gastrointestinal Functional Symptoms. A Randomized Clinical Trial. Nutrients 2016, 8, 677. [Google Scholar] [CrossRef] [PubMed]
  133. Rautava, S.; Walker, W.A. Academy of Breastfeeding Medicine founder’s lecture 2008: Breastfeeding--an extrauterine link between mother and child. Breastfeed. Med. 2009, 4, 3–10. [Google Scholar] [CrossRef] [PubMed]
  134. Dotterud, C.K.; Storro, O. Probiotics in pregnant women to prevent allergic disease: A randomized, double-blind trial. Br. J. Dermatol. 2010, 163, 616–623. [Google Scholar] [CrossRef] [PubMed]
  135. Enomoto, T.; Sowa, M. Effects of bifidobacterial supplementation to pregnant women and infants in the prevention of allergy development in infants and on fecal microbiota. Allergol. Int. 2014, 63, 575–585. [Google Scholar] [CrossRef] [PubMed]
  136. Kim, J.Y.; Kwon, J.H. Effect of probiotic mix (Bifidobacterium bifidum, Bifidobacterium lactis, Lactobacillus acidophilus) in the primary prevention of eczema: A double-blind, randomized, placebo-controlled trial. Pediatr. Allergy Immunol. 2010, 21, e386–e393. [Google Scholar] [CrossRef]
  137. Niers, L.; Martin, R. The effects of selected probiotic strains on the development of eczema (the PandA study). Allergy 2009, 64, 1349–1358. [Google Scholar] [CrossRef]
  138. Ou, C.Y.; Kuo, H.C. Prenatal and postnatal probiotics reduces maternal but not childhood allergic diseases: A randomized, double-blind, placebo-controlled trial. Clin. Exp. Allergy 2012, 42, 1386–1396. [Google Scholar] [CrossRef]
  139. Rautava, S.; Kainonen, E. Maternal probiotic supplementation during pregnancy and breast-feeding reduces the risk of eczema in the infant. J. Allergy Clin. Immunol. 2012, 130, 1355–1360. [Google Scholar] [CrossRef]
  140. Simpson, M.R.; Dotterud, C.K. Perinatal probiotic supplementation in the prevention of allergy related disease: 6 year follow up of a randomised controlled trial. BMC Dermatol. 2015, 15, 13. [Google Scholar] [CrossRef]
  141. Wickens, K.; Barthow, C. Maternal supplementation alone with Lactobacillus rhamnosus HN001 during pregnancy and breastfeeding does not reduce infant eczema. Pediatr. Allergy Immunol. 2018, 29, 296–302. [Google Scholar] [CrossRef] [PubMed]
  142. Fiocchi, A.; Pawankar, R. World Allergy Organization-McMaster University Guidelines for Allergic Disease Prevention (GLAD-P): Probiotics. World Allergy Organ. J. 2015, 8, 4. [Google Scholar] [CrossRef] [PubMed]
  143. Muraro, A.; Agache, I. EAACI food allergy and anaphylaxis guidelines: Managing patients with food allergy in the community. Allergy 2014, 69, 1046–1057. [Google Scholar] [CrossRef] [PubMed]
  144. Baldassarre, M.E.; Laforgia, N. Lactobacillus GG improves recovery in infants with blood in the stools and presumptive allergic colitis compared with extensively hydrolyzed formula alone. J. Pediatr. 2010, 156, 397–401. [Google Scholar] [CrossRef] [PubMed]
  145. Kapel, N.; Campeotto, F. Faecal calprotectin in term and preterm neonates. J. Pediatr. Gastroenterol. Nutr. 2010, 51, 542–547. [Google Scholar] [CrossRef]
  146. Tan-Lim, C.S.C.; Esteban-Ipac, N.A.R. Probiotics as treatment for food allergies among pediatric patients: A meta-analysis. World Allergy Organ. J. 2018, 11, 25. [Google Scholar] [CrossRef] [PubMed]
  147. Berni Canani, R.; Di Costanzo, M. Extensively hydrolyzed casein formula containing Lactobacillus rhamnosus GG reduces the occurrence of other allergic manifestations in children with cow’s milk allergy: 3-year randomized controlled trial. J. Allergy Clin. Immunol. 2017, 139, 1906–1913.e4. [Google Scholar] [CrossRef]
  148. Dupont, C.; Hol, J.; Nieuwenhuis, E.E. An extensively hydrolysed casein-based formula for infants with cows’ milk protein allergy: tolerance/hypo-allergenicity and growth catch-up. Br. J. Nutr. 2015, 113, 1102–1112. [Google Scholar] [CrossRef]
  149. Hol, J.; Van leer, E.H.; Elink schuurman, B.E.; de Ruiter, L.F.; Samsom, J.N.; Hop, W.; Neijens, H.J.; de Jongste, J.C.; Nieuwenhuis, E.E.; Cow’s Milk Allergy Modified by Elimination and Lactobacilli study group. The acquisition of tolerance toward cow’s milk through probiotic supplementation: a randomized, controlled trial. J. Allergy Clin. Immunol. 2008, 121, 1448–1454. [Google Scholar] [CrossRef]
  150. Kirjavainen, P.V.; Salminen, S.J.; Isolauri, E. Probiotic bacteria in the management of atopic disease: underscoring the importance of viability. J. Pediatr. Gastroenterol. Nutr. 2003, 36, 223–227. [Google Scholar] [CrossRef]
  151. Majamaa, H.; Isolauri, E. Probiotics: a novel approach in the management of food allergy. J. Allergy Clin. Immunol. 1997, 99, 179–185. [Google Scholar] [CrossRef]
  152. Viljanen, M.; Savilahti, E.; Haahtela, T.; Juntunen-Backman, K.; Korpela, R.; Poussa, T.; Tuure, T.; Kuitunen, M. Probiotics in the treatment of atopic eczema/dermatitis syndrome in infants: a double-blind placebo-controlled trial. Allergy 2005, 60, 494–500. [Google Scholar] [CrossRef] [PubMed]
  153. Kuitunen, M.; Kukkonen, K. Pro- and prebiotic supplementation induces a transient reduction in hemoglobin concentration in infants. J. Pediatr. Gastroenterol. Nutr. 2009, 49, 626–630. [Google Scholar] [CrossRef] [PubMed]
  154. Baldassarre, M.E. Probiotic Genera/Species Identification Is Insufficient for Evidence-Based Medicine. Am. J. Gastroenterol. 2018, 113, 1561. [Google Scholar] [CrossRef] [PubMed]
  155. Baldassarre, M.E. Harms Reporting in Randomized Controlled Trials of Interventions Aimed at Modifying Microbiota. Ann. Intern. Med. 2019, 170, 143. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Immunomodulation by dietary interventions. TH2 = T cell helper 2; APC = Antigen Presenting Cell; IL-2 = Interleukin-2; IL-4 = Interleukin-4; IL-5 = Interleukin-5; IL-13 = Interleukin-13; IL-10 = Interleukin-10; IFN = Interferon; T-reg = Regulatory T Cell; B-reg = Regulatory B Cell; ↑ = increase; ↓ = decrease.
Figure 1. Immunomodulation by dietary interventions. TH2 = T cell helper 2; APC = Antigen Presenting Cell; IL-2 = Interleukin-2; IL-4 = Interleukin-4; IL-5 = Interleukin-5; IL-13 = Interleukin-13; IL-10 = Interleukin-10; IFN = Interferon; T-reg = Regulatory T Cell; B-reg = Regulatory B Cell; ↑ = increase; ↓ = decrease.
Nutrients 11 01399 g001
Table 1. Probiotics administration during pregnancy and breastfeeding for the prevention of allergic disorders.
Table 1. Probiotics administration during pregnancy and breastfeeding for the prevention of allergic disorders.
Author, YearStudySubjectsStrain, Dose, Beginning of the Treatment (S), End of the Treatment (E)Placebo OutcomesFollow-Up (Years) Side Effects
Dotterud et al. [134]RCT415 pregnant womenLGG 5 × 1010 CFU, Bb-12 5 × 1010 CFU and La-5. 5 × 109 (CFU) daily
S: 4 weeks before expected delivery date
E: 3 weeks after delivery
yesProbiotic supplementation reduces incidence of atopic dermatitis (AD) in children2No
Enomoto et al. [135]Open-trial 166 pregnant women and newbornsBB536 5 × 109 CFU and BB M-16V 5 × 109 CFU daily
S: 4 weeks before expected delivery date
E: 6 months after delivery (to infants)
noProbiotic supplementation reduces incidence of AD in children3no
Wickens et al. [141]RCT423 pregnant womenLR HN001 6 × 109 CFU daily
S: from 14–16 weeks gestation
E: 6 months after delivery
yesProbiotic supplementation does not prevent AD in infants 1no
Ou et al. [138]RCT191 pregnant women and related newbornsLGG ATCC 53103, 1 × 1010 CFU daily
S: From the second trimester of pregnancy;
E: 6 months after delivery (to mothers and infants) during breastfeeding
yesProbiotic supplementation doesn’t prevent infant allergic disease (AD, allergic rhinitis, asthma)3no
Rautava et al. [139]RCT241 pregnant womenLPR 1 × 109 CFU BL999 1 × 109 CFU ST11 1 × 109 CFU daily
S: 2 months before expected delivery
E: 2 months after delivery (breast-feeding)
yesProbiotic supplementation prevents infant eczema 2Not observed
Kim et al. [136]Randomized placebo-controlled trial112 pregnant women and newbornsBGN4 1.6 × 109 CFU, AD011 1.6 × 109 CFU, and AD031 1.6 × 109 CFU daily
S: 4–8 weeks before expected delivery
E: 6 months after delivery (to mothers during breastfeeding and to infants)
supplementation reduces incidence of AD in children
Niers et al. [137]Double-blind, randomized, placebo-controlled trial 136 pregnant women and newbornsBB: 1 × 109 CFU; BL 1 × 109 CFU; LL 1 × 109 CFU
S: last 6 weeks of pregnancy
E: 12 months after delivery (to infants)
yesProbiotics supplementation reduces the incidence of AD in children at 3 months of life 24 months after delivery no
Simpson et al. [140]Randomized placebo-controlled trial 415 pregnant womenProbiotic milk: LGG, 5 × 1010 CFU; La-5 5 × 109 CFU and Bb-12 5 × 1010 CFU
S: from 36 weeks gestation
E: 3 months after delivery (breastfeeding)
yesProbiotics supplementation reduces incidence of AD 6 years after delivery no
LGG: Lactobacillus rhamnosus GG; Bb-12: Bifidobacterium animalis subsp. Lactis Bb-12; La-5: L. acidophilus La-5; CFU: colony-forming unit; BB536: B. longum BB536 [ATCC BAA-999]; BB M-16V: B. breve M-16V [LMG 23729]; LR HN001: Lactobacillus Rhamnosus HN001; LG LPR: Lactobacillus rhamnosus LPR; BL999: Bifidobacterium longum BL999. ST11: L paracasei ST11; BGN4: Bifidobacterium bifidum BGN4; AD011: Bifidobacterium lactis AD011; AD031: Lactobacillus acidophilus AD031; BB: Bifidobacterium bifidum; BL: Bifidobacterium lactis; LL: Lactococcus lactis; AD: Atopic Dermatitis.
Table 2. Probiotics in cow’s milk allergy CMA treatment.
Table 2. Probiotics in cow’s milk allergy CMA treatment.
Author, YearStudy DesignSubjectsStrain, Dose (D)Placebo OutcomesTreatment Period
Side Effects
Baldassarre et al. [144]RCT30 infantsLGG 1 × 106 CFU/g yesProbiotic supplementation improves gastrointestinal symptoms (hematochezia and fecal calprotectin)1No
Berni Canani et al. [79]RCT80 infantsLGG, 1.4 × 107 CFU/100 mLyesProbiotic supplementation accelerates tolerance acquisition to cow’s milk proteins12 No
Berni Canani et al. [80]RCT260 infantsLGG (dose not specified)yesProbiotic supplementation accelerates tolerance acquisition to cow’s milk proteins12 No
Berni Canani et al. [147]RCT 220 childrenLGG (dose not specified)yesProbiotic supplementation reduces the incidence of other allergic manifestations and hastens the development of oral tolerance to cow’s milk proteins36 No
Dupont et al. [148]RCT119 infantsLC CRL431 and Bb-12 (dose not specified)yesProbiotic supplementation significantly improves the SCORAD index and growth indices6 No
Hol et al. [149]RCT119 infantsLC CRL431 and Bb-12 1 × 107 CFU/g formulayesProbiotic supplementation does not accelerate tolerance acquisition to cow’s milk proteins6No
Kirjavainen et al. [150]RCT35 infantsLGG ATCC 53103 1 × 109 CFU/gyesSupplementation with viable probiotics improves the SCORAD index2Diarrhea (with heat-inactivated LGG)
Majamaa et al. [151]RCT31 infantsLGG ATCC 53103- 5 × 108 CFU/g formula twice a day yesProbiotic supplementation improves the SCORAD index and reduces markers of intestinal inflammation 1No
Viljanen et al. [152]RCT230 infantsLGG (ATCC 53103) 5 × 109 CFU vs. LGG 5 × 109 CFU, LR LC705- 5 × 109 CFU, Bbi99- 2 × 108 CFU, and PJS- 2 × 109 CFU twice a dayyesProbiotic supplementation improves the SCORAD index in IgE-sensitized infants but not in non-IgE-sensitized infants1No
LGG: Lactobacillus rhamnosus LGG; CFU: colony-forming unit; LC CRL431: L. casei CRL431; Bb12: B. lactis Bb-12 (B animalis subspecies lactis); LR LC705: L. Rhamnosus LC705 Bbi99: Bifidobacterium breve Bbi99; PJS: Propionibacterium JS.

Share and Cite

MDPI and ACS Style

D’Auria, E.; Salvatore, S.; Pozzi, E.; Mantegazza, C.; Sartorio, M.U.A.; Pensabene, L.; Baldassarre, M.E.; Agosti, M.; Vandenplas, Y.; Zuccotti, G. Cow’s Milk Allergy: Immunomodulation by Dietary Intervention. Nutrients 2019, 11, 1399.

AMA Style

D’Auria E, Salvatore S, Pozzi E, Mantegazza C, Sartorio MUA, Pensabene L, Baldassarre ME, Agosti M, Vandenplas Y, Zuccotti G. Cow’s Milk Allergy: Immunomodulation by Dietary Intervention. Nutrients. 2019; 11(6):1399.

Chicago/Turabian Style

D’Auria, Enza, Silvia Salvatore, Elena Pozzi, Cecilia Mantegazza, Marco Ugo Andrea Sartorio, Licia Pensabene, Maria Elisabetta Baldassarre, Massimo Agosti, Yvan Vandenplas, and GianVincenzo Zuccotti. 2019. "Cow’s Milk Allergy: Immunomodulation by Dietary Intervention" Nutrients 11, no. 6: 1399.

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop