In the present issue of Allergologia et Immunopathologia,1 the Spanish Society of Paediatric Allergy, Asthma and Clinical Immunology (SEICAP) and the Portuguese Society of Paediatric Allergy (SPAP) present a consensus on the Cow's Milk Allergy: the so called CIBAL Study (Consenso IBérico sobre Alergia a la Leche). The CIBAL consensus surveyed 160 experts (116 from Spain and 44 from Portugal) who were asked about prevention, diagnosis, treatment and progression of the condition. The survey followed the Delphi method and arrived at many agreements on the questions formulated. However, there were also some discrepancies, what I would like to underlie in these lines as can be more revealing that the agreements.
In the section on prevention, disagreement (as defined by “same answer is not given by at least 50% of panellists”) was found in the following questions: 1. “Exclusive breastfeeding is recommended up to 6 months, or at least up to 4 months, to reduce food allergies in general”; “Partially hydrolysed formulas (pHf) administered from birth up to 6 months to supplement or replace breast milk are effective in preventing CMPA in infants with atopic risk”; “pHf and hydrolysed fomulas (eHf) have a preventive effect on atopic dermatitis compared to formulas containing intact proteins”; and “An infant receiving adapted cow's milk formula continuously from birth will develop tolerance and not present symptoms, even if sensitisation develops”. The lesson from these discrepancies is either there is a lack of evidence in the literature or there is noise coming from interested parties, or both. Hydrolysed formulas (either pHF or eHf) are more expensive that adapted formulas and general paediatricians in primary care settings should have a clear idea as what to do, especially if their position can add some burden (albeit probably negligible) to the Spanish Health System. A clarification on these points, if possible, and the dissemination of a congruent position is probably needed both in Spain and Portugal. If the evidence is not conclusive it seems reasonable to go for the cheapest option and plan a study to try and clarify the position of both societies.
In the section on diagnosis, no statement generated discrepancy, which is reassuring. In the section on treatment, the only discrepancy was in the question: “Hydrolysed formulas have bad taste and the majority of children reject them”. It is quite possible that hydrolysed formulas have several tastes that might have diverse reactions in different infants and thus, the experts have discrepant experiences. As previously said, maybe SEICAP and SPAP can launch a multicentre and well controlled study (including different brands) which might clarify this point. It seems a cheap but interesting one. In this same section, it is quite striking that there was discrepancy in a quite important statement as: “There is insufficient evidence of effectiveness and safety of oral immunotherapy (OIT) with cow's milk for it to be used during routine clinical practice. It should currently be limited to clinical research studies at specific centres (experienced staff and suitable equipment), following protocols approved by ethics committees”. It is also of interest that 37.89% of experts completely disagreed or disagreed, while exactly the same proportion (37.89%) completely agreed or agreed. OIT is a very important treatment procedure which needs time and dedication of health personnel. Its usefulness has been well documented and probably should be implemented in reference units which have experienced staff and the needed equipment.
To end, the section on progression revealed discrepancy in the following statements: “Accidental ingestion of milk worsens the prognosis towards persistence of the allergy”; “If a patient has had no any symptoms for two years, the cautious, controlled challenge test can be assessed independently of SPT and IgE levels”; and “If a patient has had no symptoms for two years, the cautious, controlled challenge test can be assessed only if it is verified that SPT diameter and IgE levels have reduced”. All three are important to clarify.
Is summary, the SEICAP and SPAP have made a considerable effort to put this consensus forward. This is what scientific societies are for. However, both societies should try and clarify the discrepant statements either with a more profound study of the literature or implementing studies that can support a specific position.
