Rachael Zimlich, RN, BSN

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Children who have cow’s milk allergies may struggle with long-term growth moreso than their peers with other food allergies, according to a recent study.

 on the effect of milk allergies on overall childhood growth was published through a letter to the editor in the 

Journal of Allergy and Clinical Immunology

. Food allergies are prevalent in childhood, but some food allergic children may be at risk for decreased growth measures. Previous research has suggested that food allergies and elimination diets can affect childhood growth and nutrition, and that milk or multiple food allergies are especially problematic in this way. Information on growth patterns has been lacking for children in these groups, making it difficult to determine the long-term effects of food allergies and diet restrictions may have.

Lead author Karen Robbins, MD, from the Division of Allergy and Immunology at Children’s National Health System in Washington, DC, says the goal of the research was to describe growth patterns of children with cow’s milk allergy longitudinally, as they develop from early childhood to adolescence.

“There has been research to look at growth in children with food allergy, but most of these studies only look at children at one point in time,” she says. “Decreased growth has been observed in the past, but previous work has not addressed whether these children achieve catch-up growth. Furthermore, all food allergies are not the same, and cow's milk allergy specifically may be a risk factor for growth and/or nutritional problems.”

The research team used a retrospective review of children enrolled at the Johns Hopkins Pediatric Allergy Clinic in Baltimore, Maryland, who had persistent food allergies and strict elimination diets. Children with other conditions beyond food allergies that may have negatively impacted their growth were excluded.

Nearly 200 children were included in the final study, with data from more than 1100 clinic visits reviewed. The children primarily had cow’s milk or peanut and tree nut allergies.

The research team found that, as in prior studies, children with cow’s milk allergies typically restricted other foods from their diet that are common allergens. These included eggs, peanuts, and tree nuts. However, the researchers found that children with cow’s milk allergies also had lower weights and heights than even their peers with peanut and tree nut allergies. The presence of other conditions like asthma and eczema or inhaled corticosteroid use had no significant effect on the findings. Additionally, decreases in weight and heights among children with persistent milk allergies became more pronounced as the children aged.

“Children with persistent cow's milk allergy—meaning, cow's milk allergy that does not resolve in early childhood—are at risk for decreased growth,” Robbins says. “It is important to follow their growth and nutrition closely, pay attention to other factors that could also impact growth, such as repeated courses of steroids in uncontrolled asthma or eating problems, and offer additional support if needed.”

The report outlines the long-term challenges of milk allergies and the impact food restrictions attributed to those allergies could have on growth as children age. Although the research team says a true control population was not possible in this study, there were children with cow’s milk allergies who only avoided nuts and not other foods, allowing for a wider comparison of strict versus non-strict diet restrictions on growth and development. The study also notes that throughout the study years, the team observed improved access and referral to dietary advice, improved information about food allergen ingredients in foods, and wider availability of allergen-free foods which may have impacted long-term growth and diet options.

Overall, the team’s research was limited because it was a retrospective study, but the study did conclude that children with cow’s milk allergies were lighter and smaller than their peers with nut allergies, and that growth problems increased as they aged if their allergy persisted.

“It is not entirely known what explains the growth differences in these children, but that is an important question to address next,” Robbins says. “Most children with cow's milk allergy had multiple food allergies, so cow's milk allergy may just be a marker for children with multiple food allergies. It is possible that the allergic condition impacts growth, since most of the children with cow's milk allergy had multiple food allergies or avoidances and many had asthma. There could also be some differences in nutritional intake and/or maladaptive eating patterns, or children with food allergies may watch their intake more carefully.”

If a child has unpleasant experiences such as allergic reactions with food, this could impact their diet and eating habits, she notes.

“Some children could have nutritional deficiencies, but that was not addressed in this study,” Robbins adds. “Furthermore, there may be factors that we do not know at this time. We did not conclude that size or growth may contribute to reaction to cow's milk or assess for this, because that was not an aim of the study.”

Robbins says the study found that these children can benefit from nutritional guidance, and it is important for primary care providers and allergists to monitor diet, nutrition, and growth closely. Referral to a registered dietician should be considered, as well, she says.

“Ideally, this research will highlight growth and diet as important topics to address for food allergic children, especially those with cow's milk allergy, multiple food allergies, and other medical conditions that could impact growth,” Robbins says. “I also hope that it allows for ongoing study of the impact of allergy on childhood growth and development.”

Robbins K, Wood R, Keet C. Persistent cow’s milk allergy is associated with decreased childhood growth: a longitudinal study. 

. 2020:145(2):713-716.e4. doi:10.1016/j.jaci.2019.10.028

Articles

A retrospective study reveals that children with cow’s milk allergies—and the restrictive diets they must follow—may negatively impact their growth and development in comparison to their peers with other food allergies.

Children with cow’s milk allergies smaller, lighter than peers with nut allergies

Peanut allergies are one of the most common food allergies in children, with prevalence increasing significantly over the last few decades. Emerging evidence supports early peanut introduction as a tool to combat peanut allergies, but this is still considered a controversial step in allergy management.

A recent report set out to investigate advances in peanut allergy diagnosis and treatment, as well as some of the barriers to accepting these therapies. 

, reveals that although there is a lot of progress being made in mitigating peanut allergies, there is still a lot of debate about the best steps to take.

Peanut allergies affect roughly 1% to 3% of children and although the number is relatively small, the impact is great. Peanut allergies have a significant negative impact on quality of life, highlighting the importance of accurate diagnosis and management early on, the study notes.

Whereas peanut allergies may be more common in children with immediate family members who also have a peanut allergy, peanut allergies can be rooted in both genetic and environmental factors, according to the report. For example, the study notes some evidence pointing to vitamin D deficiencies and high latitudes being associated with higher rates of both peanut allergies and anaphylactic reactions to exposures.

The report highlights recent acceptance that the 

 supports the idea that avoidance of certain foods—like peanuts—in a child’s early years can lead to an increased chance of allergic reactions later. Specifically, the theory suggests that allergen exposure in these children happens through cutaneous exposure whereas eating allergenic foods appears to increase immune tolerance. This theory is related to mutations of the FLG gene, which has been linked to atopic dermatitis. Therefore, early peanut introduction has emerged as a preventive tool in mitigating peanut allergies.

Early peanut introduction has been tested in a number of studies over more than a decade, with one of the most recent reports indicating that allergy risk is reduced when peanuts are introduced to children between 4 and 11 months of age.

 These studies have led the National Institute of Allergy and Infectious Diseases (NIAID) to release a guideline on preventing peanut allergies in 2017 that included a recommendation to introduce peanut-containing foods as early as 4 to 6 months of age in infants with severe eczema and/or egg allergies.

Despites strong recommendations in the United States and abroad, a number of questions about using peanut exposure to combat allergy development remain. A few of these include the amount and frequency of peanut products that have to be ingested to the best effect, and how well this therapy works on children who are at lower risk of developing peanut allergies. There is also some controversy as to whether high-risk infants should have additional screenings before starting peanut introduction. These tests have high false negative rates and although the guidelines suggest additional testing for children with other severe allergies, international recommendations do not. This could lead to a slippery slope when it comes to costly screening, the study notes. There are certain criteria that should be used when considering preemptive testing for peanut allergies, and clinicians should consider balance and practicality when making a decision on testing protocol. Medically supervised oral food challenges are the “gold standard” for peanut allergy diagnosis. Development of better—more effective and less risky—testing methods are still needed, the authors add.

The study also tackles the controversy surrounding peanut bans in schools and other facilities, noting the low risk of accidental exposure in these environments, as well as low efficacy of these bans in preventing accidental ingestion. The more pressing issue, the study notes, is how ill-prepared most of these facilities are for dealing with allergic reactions when they do occur.

Immunotherapies like early peanut exposure have been shown to have a significant effect on the development of peanut allergies, but this treatment remains controversial to some for the level of risk it presents with uncertain benefit. The focus should be more research aimed at home to improve quality of life in children with peanut allergies.

1. Abrams EM, Chan ES, Sicherer S. Peanut allergy: new advances and ongoing controversies. 

. 2020:145(5):e20192102. doi:10.1542/peds.2019-2102

2. West C. Introduction of complementary foods to infants. 

. 2017:70(2):47-54. doi:10.1159/000457928

3. Ierodiakonou D, Garcia-Larsen V, Logan A et al. Timing of allergenic food introduction to the infant diet and risk of allergic or autoimmune disease. 

. 2016: 316(11):1181. doi:10.1001/jama.2016.12623

4. Togias A, Cooper SF, Acebal ML, et al. Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. 

 2017:139(1):29-44. doi:10.1016/j.jaci.2016.10.010

There are a number of ways clinicians can tackle peanut allergies, but allergy screening and early peanut exposure are still up for debate.

Study suggests new strategies to combat peanut allergies bring both progress and controversy

A recent study reveals that autism rates are dropping among children living in wealthy white areas of California while rising in poor, minority areas, but the reason why isn’t exactly clear.

Journal of Autism and Developmental Disorders

, reviewed autism prevalence among children born in different areas of California between 1993 and 2000. Data for the study came from children in the California Department of Development Services system.

Although prevalence increased fairly equally among all the children in the study born between 1993 and 2000, the research noted that prevalence remained steady or declined in children from wealthy white areas in the years that followed. At the same time, autism prevalence continued to increase after 2000 and until the study concluded in 2013 among both white and Hispanic children in low income areas.

However, the downward trend in diagnoses among wealthier white children may not be what is appears. Rather than a natural decrease in cases, the study team suggests that perhaps the decline is more of a result of these families seeking private care for their children—therefore excluding them from the state tracking system—or making other changes that could reduce their autism risk.

“Autism was once considered a condition that occurs mainly among white children of high socioeconomic status, but my current study suggests that ethnic minorities and low income families are increasingly experiencing higher rates of autism spectrum disorder (ASD), particularly severe autism,” says Cynthia Nevison, PhD, lead author of the study and a researcher from the University of Colorado in Boulder. “The logical implication is that the etiology of ASD is primarily environmental and that ASD risk can be influenced by parental choices, behavior, and access to resources.”

Prevalence for autism nationwide is about 1 in 59, or roughly 2% of 8-year-olds in the most recent Autism and Developmental Disabilities Monitoring (ADDM) Network from 2006. In that survey, prevalence had increased from the two previous surveys in 2002 and 2004, when prevalence was 1 in 68. Another survey, the National Health Interview Survey (NHIS), estimated prevalence in 2016 at about 1 in 36 among children aged 3 to 17 years compared to a prevalence of 1 in 45 2 years prior. In comparison, estimates of prevalence in the early 1990s were 1 in 150, and 1 in 2500 in the early 1980s.

Although autism prevalence appears to have increased significantly over the decades, more recent reports have indicated that this trend may be slowing or reversing—particularly among certain socioeconomic and ethnic groups. A 

 from the Centers for Disease Control and Prevention seems to back this idea, attributing a 15% drop in ASD to a narrowing gap in prevalence between white children and children from minority groups.

Nevison and other researchers examined newer data that confirmed that autism rates were increasing faster among black and Hispanic populations when compared to white children. Historically, prevalence of autism in minority groups had been lower than among whites, but the more recent review found that the rates of autism among black children in particular had not only caught up to that of white children, but had surpassed it in most states.

To investigate further, Nevison and her colleagues examined this newest cohort, breaking down prevalence rates by race and ethnicity, as well as by county. The county-level analysis allowed for an evaluation of autism prevalence by race/ethnicity, as well as specific income groups.

Researchers found that statewide prevalence of autism in California was 1.5% by the 2013 birth year group, with the highest prevalence of 1.8% found in black children, followed by 1.7% in Asian children, 1.4% in white children, and 1.2% in Hispanic children. There was a continuous growth in prevalence throughout the cohort from 1993 to 2013, but a flattened curve was noted in all groups except for Hispanic, and most noticeably among white children. Flattening was short-lived in most of the ethnic groups, the report notes, and was shortest among black children.

In terms of wealth, the research team also noted at growth rates were similar from 1993 to 2000, but after 2000 autism prevalence decreased in the wealthiest California counties. Increases continued but were slower in middle income areas, and were consistent across the study years in low income counties.

The finding in this study that autism prevalence among black children matched and then exceeded that of white children challenges previous theories that increased prevalence is a function of autism awareness and access to care, according to the report. Black and Hispanic children have typically had lower access to care, but increased emphasis on services for low income children may have helped to close these gaps in care.

A number of theories have been proposed to explain the differences in autism prevalence in various socioeconomic areas including, genetics, environments, access to care, and therapy choices. There is also a link to risk factors that could have an impact based on socioeconomic factors including immune inflammation and oxidative stress, diet quality, chronic stress, and more.

“Rising ASD rates among minority children generally are interpreted to suggest that these children have been underdiagnosed in the past and are now catching up to wealthy, white children due to better pediatric screening and awareness. There is likely truth to that view, but it also involves questionable assumptions, such as that there is a natural or genetic level of ASD prevalence in the population, that white ASD rates have more or less stabilized at that level, and that minorities are now catching up thanks to improved screening and will stabilize at a similar level. Those assumptions aren’t supported by data showing that minority ASD rates are surpassing white rates in many states and counties, and that ASD rates among low income whites are continuing to increase.”

Nevison says an alternative explanation is that minority children didn’t experience ASD at the same level as wealthy white children in the past, and that prevalence is genuinely increasing in this population.

“The fact that my study used an age-resolved snapshot from 2019—in which older minority children in that snapshot had lower rates of diagnosed ASD in 2019 than younger children—supports this latter, alternative explanation,” Nevison. “However, pediatricians might consider whether ASD has been missed or underdiagnosed in their older patients, especially among minority children and teenagers.”

This means ASD would join a number of other conditions like diabetes, asthma, and obesity that are more prevalent among the poor as a result of toxin exposure, poor diets, and other factors that lead to chronic inflammation.

The authors lean toward the conclusion that wealthy, educated parents in predominantly white areas likely opted out of public services programs for their children and began making lifestyle and care choices that lowered their likelihood of an autism diagnosis. Nevison says some of the changes observed in those communities as ASD cases fell could be implemented in lower income areas, but it would take a concerted effort to identify the environmental factors that cause ASD.

“Historically about 95% of ASD research funding has gone toward genetics. Many research institutions are still largely following a paradigm that views ASD as a genetic rather than an environmental condition,” Nevison says. “Wealthy parents in California appear to have moved beyond that paradigm and succeeded in lowering their children’s ASD risk. Hopefully the research community can follow their lead and conduct studies to understand what these parents have been doing.”

have also suggested a breakdown of ASD trends along private versus public insurance lines. She says she hopes her study will motivate more research, and inspire clinicians to examine their own practices and those in their communities.

“This may simply reflect underlying socioeconomic factors, as mentioned above, but may also suggest that children on Medicaid and Children's Health Insurance Program are receiving a lower standard of care than privately insured children,” she says. “Pediatricians in clinical practice might consider whether they are treating lower income and minority children differently than wealthier white and Asian children and move to address those disparities.”

1. Nevison C, Parker W. California autism prevalence by county and race/ethnicity: declining trends among wealthy whites. 

. March 19, 2020. Epub ahead of print. doi:10.1007/s10803-020-04460-0

2. Christensen D, Baio J, Braun K, et al. Prevalence and characteristics of autism spectrum disorder among children aged 8 years — Autism and Developmental disabilities Monitoring Network, 11 Sites, United States, 2012. 

. 2016:65(3):1-23. doi:10.15585/mmwr.ss6503a1

3. Pearl, M., Matias, S., Poon, V., & Windham, G. Trends in birth prevalence of autism spectrum disorder (ASD) in California from 1990 to 2010, by race-ethnicity and income. Poster presented at: 2019 International Society for Autism Research Annual Meeting; May, 2010; Montreal, Canada.

A recent study investigates what is causing ASD to drop in wealthy, white California.

Drop in autism by ethnicity, class may not be what it seems

Researchers have shortened the assessment tool used to determine pharmacologic treatment options for newborns exposed to opioids in the womb and say the changes could help increase the tool’s clinical utility.

Finnegan Neonatal Abstinence Scoring Tool (FNAST)

, used to gauge signs of opioid exposure and withdrawal at birth, could be simplified.

According to the report, both medical and nonmedical opioid use has increased significantly, from 1.5 per 1000 live births in 1999 to 6.5 per 1000 live births in 2014. Exposure to opioids in the womb, from mothers with Opioid Use Disorder (OUD), resulted in a five-fold increase in babies born with problems from opioid exposure. These problems, labeled neonatal abstinence syndrome (NAS), are rooted in the passive maternal transfer of opioids during pregnancy, followed by withdrawal symptoms at birth when that transfer ends. It can be difficult to assess, and therefore treat, neonatal withdrawal as these infants can’t communicate their symptoms, and there is a wide variation in expressions of these symptoms.

“Every neonate exposed to opioids in utero is somewhere along the continuum of withdrawal,” the report notes. “Although some neonates have mild signs and normal physiologic functions, others have more severe NAS that requires pharmacologic treatment to avoid major complications. Differences in the expression of NAS are associated with many factors, including the type of opioid exposure, co-exposure with other illicit drugs and/or psychotropic medications, genetic and epigenetic variability, the gestational age and sex of the neonate, breastfeeding, and parental engagement.”

For decades, observational assessments have been used to determine the severity of NAS and guide treatments with pharmacologic therapy. These observations are subjective, however, and variations between how different clinicians rate symptoms have been shown to result in significant differences in the initiation and duration of medications for NAS, the length of time required in the hospital, and health care utilization rates.

The FNAST is the most commonly used test for assessing infants with NAS. However, this 21-item assessment has some sections with 2 to 4 subcategories each, plus multiple scoring tools for those subcategories. Although complex and lengthy, the FNAST has shown reliability among various observers despite differences in observations. Several attempts have been made to condense the FNAST, but there have been limited data on the success of those attempts.

The goal of this study was to make the FNAST shorter and simpler by only focusing on withdrawal symptoms that required timely clinical intervention. The study team developed a set of questions to test their simplified FNAST, trialing the new tool in a cohort of 424 neonates born with opioid exposure. The infants in the study had a gestational age of at least 36 weeks and were followed from birth to hospital discharge. The team found that the simplified tool worked nearly as well as the original FNAST at discriminating between infants who did and did not receive treatment.

Lead study author Lori Devlin, DO, MHA, FAAP, associate professor of Pediatrics and director of the Neonatal Fellowship Program at the University of Louisville School of Medicine in Kentucky says the simplified FNAST focuses on 8 measures instead of 21, highlighting those that highly correlate with the receipt of pharmacologic therapy.

“These items are dichotomized-present or absent-and able to discriminate between infants who receive pharmacologic therapy and those who do not almost as effectively as the original FNAST,” Devlin says. “This shorter and dichotomized assessment tool could simplify clinical assessment by focusing on components of the original FNAST that are relatively consistent across multiple sites. After prospective validation of the tool, it could be widely used and standardize the approach to neonates with NAS.”

Specific changes that were made to the FNAST were the removal of convulsions, a high-pitched cry, and a hyperactive Moro reflex from the assessment. Convulsions were not observed in the study group, and the other 2 symptoms were determined to be too variable in nature across the study group to be well-assessed. Two items dealing with tremors were combined into 1, and only 8 of the remaining 17 test items were independently associated with pharmacologic treatment,.

The study team concluded that pharmacologic treatment for NAS may be able to be determined using just 8 criteria from the FNAST. Condensing this tool could allow for a more streamlined assessment of when a neonate needs pharmacologic therapy for NAS and enhance the clinical utility of the FNAST.

“The goal of our research was to determine if a simplified Finnegan Scoring Tool could discriminate the receipt of pharmacologic therapy as effectively as the original FNAST,” Devlin says.

As to whether Devlin and her team are advocating a change in clinical practice, she says it may be too soon to say.

“Our research focused specifically on the development of a simplified tool to assess for NAS,” she says. “We are not proposing changes in intervention or treatment protocols, as prospective clinical studies are needed to answer to such questions.”

 that accompanied the study was in agreement, noting that there just isn’t enough data on the long-term effects of NAS and its treatments.

 Acknowledging the benefits of a shortened tool and the efforts of Devlin’s team, the commentators questioned whether limiting assessment categories could result in missing rare and complicated expressions of NAS.

“The simplicity of this tool is attractive. However, before it can be embraced in clinical care, several questions remain to be answered,” wrote Ju Lee Oei, MD, of the University of New South Wales in Kensington, Australia, and Trecia Wouldes, PhD, of the University of Auckland, New Zealand.

Only one score was used to determine treatment, they note, and withdrawal systems change with time. This could lead to missed observations, and consistency over time is key to a proper assessment.

“The rare or uncommon items, such as seizures, were removed, but this may have limited the ability of the scale to detect severe but rare manifestations of withdrawal that require urgent treatment rather than continued observation,” the commentary notes.

Where the commentators did agree, without a doubt, was with the researchers’ call for more study on NAS and assessment tools such as the FNAST. Devlin says her team is already working on additional studies of their simplified tool.

“We hope that a standard approach using this simplified clinical tool will facilitate identifying high-risk neonates who require pharmacologic therapy for NAS,” Devlin says. “The next step is prospective studies to validate our findings. Such studies are currently under development.”

1. Devlin LA, Breeze JL, Terrin N, et al. Association of a simplified Finnegan Neonatal Abstinence Scoring Tool with the need for pharmacologic treatment for neonatal abstinence syndrome. 

 2020;3(4):e202275. doi:10.1001/jamanetworkopen.2020.2275

2. Oei JL, Wouldes T. Will simplifying the Finnegan Neonatal Abstinence Scoring Tool improve outcomes for infants with opioid exposure? 

 2020;3(4):e202271. doi:10.1001/jamanetworkopen.2020.2271

A simplified assessment could determine the need for medications to treat opioid withdrawal in neonates more quickly.

Author | Rachael Zimlich, RN, BSN

Articles

Children with cow’s milk allergies smaller, lighter than peers with nut allergies

Study suggests new strategies to combat peanut allergies bring both progress and controversy

Drop in autism by ethnicity, class may not be what it seems

Researchers test simplified assessment for neonates with opioid exposure