|Year : 2016 | Volume
| Issue : 4 | Page : 874-880
The role of specific IgE antibodies in infants with cow milk protein allergy
Hatem M El-Sebay1, Eman A. E. Badr1, Yasser El-Ghobashi1, Marwa M. I. Khalil BSc 1, Ghada M El-Mashad2
1 Department of Medical Biochemistry, Menofia University, Menofia, Egypt
2 Pediatric Department, Faculty of Medicine, Menofia University, Menofia, Egypt
|Date of Submission||15-Jan-2015|
|Date of Acceptance||26-Feb-2015|
|Date of Web Publication||21-Mar-2017|
Marwa M. I. Khalil
Medical Biochemistry Department, Faculty of Medicine, Menofia University, Menofia, 32511
Source of Support: None, Conflict of Interest: None
This article aims to evaluate the role of lactoglobulin-specific IgE and lactalbumin-specific IgE in cow milk allergy.
Allergy to cow milk is the most common food allergy in infants and young children. Symptoms of milk allergy reaction can range from mild symptoms such as hives, to severe symptoms, such as anaphylaxis. The allergy is most likely to persist in children who have high levels of cow milk antibodies in their blood. The aim of this study is to assess the value of lactalbumin-specific IgE and lactoglobulin-specific IgE in the diagnosis of cow milk protein allergy.
Participants and methods
This study was carried out on 70 participants classified into the following groups: group 1: it included 50 infants with suspected cow milk protein allergy, who were diagnosed with chronic diarrhea with a history of recent introduction of cow milk and a positive elimination test. Group 2: it included 20 age-matched and sex-matched apparently healthy participants. Their ages ranged between 8 and 18 months. All individuals included in this study were subjected to full history taking, clinical examination, complete blood count, and determination of serum total IgE, lactoglobulin-specific and lactalbumin-specific IgE which was carried out using the enzyme-linked immunosorbent assay technique.
The diagnostic accuracy of lactoglobulin IgE in the diagnosis of cow milk protein allergy was 84%, with sensitivity of 78%, specificity of 100%, positive predictive value of 100%, and a negative predictive value of 65% at the cutoff point of 0.345 IU/ml. The diagnostic accuracy of lactoalbumin IgE in the diagnosis of cow milk protein allergy was 83%, with sensitivity of 84%, specificity of 80%, positive predictive value of 91%, and negative predictive value of 67% at the cutoff point of 0.335 IU/ml.
Lactalbumin-specific and lactoglobulin-specific IgE assays are important in the diagnosis of cow milk protein allergy and their combination may give better diagnostic accuracy than the total IgE assay.
Keywords: cow milk allergy, immunoglobulins, milk proteins, specific IgE
|How to cite this article:|
El-Sebay HM, Badr EA, El-Ghobashi Y, Khalil MM, El-Mashad GM. The role of specific IgE antibodies in infants with cow milk protein allergy. Menoufia Med J 2016;29:874-80
|How to cite this URL:|
El-Sebay HM, Badr EA, El-Ghobashi Y, Khalil MM, El-Mashad GM. The role of specific IgE antibodies in infants with cow milk protein allergy. Menoufia Med J [serial online] 2016 [cited 2020 Mar 29];29:874-80. Available from: http://www.mmj.eg.net/text.asp?2016/29/4/874/202533
| Introduction|| |
Nutrition is a significant factor in the growth, development, and overall functioning of a child. Good nutrition provides the energy and nutrients essential to sustain life and promote physical, social, emotional, and cognitive development .
Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly following exposure to a given food .
Allergy to cow milk protein is an immunologically mediated reaction to one or more of the milk proteins. These proteins include caseins and whey proteins .
The immunological mechanisms that lead to the development of cow milk protein allergy have still not been clarified. There are different mechanisms that contribute to the pathogenesis and the main two described mechanisms at the basis of this disease refer to immediate or delayed response .
Cow milk allergy (CMA) can be further split into IgE and non-IgE (mostly cellular) mediated. While IgE-mediated reactions are well recognized with validated diagnostic tests, the non-IgE-mediated immune reactions are not so well defined and are more difficult to recognize .
IgE-mediated allergy is associated with atopic manifestations such as urticaria, angioedema, vomiting, diarrhea, eczema, rhinitis, and anaphylaxis. Non-IgE-mediated allergy is associated with symptoms including gastroesophageal reflux, vomiting, constipation, hemosiderosis, malabsorption, villous atrophy, eosinophilic proctocolitis, enterocolitis, and eosinophilic esophagitis .
The prevalence of food allergy varies from 6 to 8% in children, and is currently increasing in many countries. Among all food allergens, cow milk is one of the most common and often the first food introduced into the infant diet, even during breastfeeding. CMA affects ˜2.5% of children and may occur early in life, even during the neonatal period .
There is no one symptom pathognomonic of CMA; it can present with an array of symptoms affecting different organ systems typically the skin, respiratory, and gastrointestinal tracts with many infants developing symptoms in more than one organ system .
There are many confirmatory tests which can add value when diagnosing CMA .
Specific IgE testing helps to confirm diagnosis in IgE-mediated allergy, and prick tests can be used to add value to the diagnosis .
The aim of this study is to assess the value of serum levels of total IgE, lactalbumin-specific IgE, and lactoglobulin-specific IgE in patients suspected to have cow milk protein allergy.
| Participants and Methods|| |
This study was carried out on 70 participants, 50 infants with milk protein intolerance and 20 apparently healthy persons. There were 31 females and 39 males with age ranging from 8 to 18 months. The patients were attendants of outpatients clinic and inpatients of Pediatrics Department, Menofia University Hospital during the period from April 2013 to January 2014. This study was approved by the ethical committee of the Faculty of Medicine, Menofia University.
They were classified into the following groups:
This group included 50 infants with suspected cow milk protein allergy. There were 21 girls and 29 boys with a mean age of 11.36 ± 3.46 months.
- The presence of chronic diarrhea.
- History of recent introduction of cow milk into their diet.
- The presence of any signs of allergy including eczema and/or bronchial asthma.
This group included 20 age-matched and sex-matched apparently healthy participants. There were 10 girls and 10 boys with a mean age of 10.60 ± 3.56 months.
All patients were subjected to the following procedures:
- History taking: Including history of the disease: onset, duration, presence of prior episodes of diarrhea and its association with the introduction of cow milk and history of breast feeding. Family history of milk allergy or any other type of food allergies.
- Complete clinical examination: Measurement of the weight and height of the infant to know if the infant growth is retarded or not. Search for signs of dehydration (such as sunken eyes, thirst, and delay in return of abdominal skin fold) to assess the severity of diarrhea and vomiting. Examination of the skin for any urticarial rash. Auscultation of the chest wheezes to know if the respiratory tract is involved or not.
- Laboratory investigations were conducted for both patients and controls including: complete blood picture, serum total IgE, lactalbumin-specific IgE, lactoglobulin-specific IgE, total proteins, and albumin levels.
Five milliliters of venous blood were taken from each participant and divided as follows: 2 ml were put immediately in an EDTA tube for complete blood count, while the remaining 3 ml were put in a plain tube, left to clot for 30 min at room temperature and then subjected to centrifugation for 10 min at 4000 rpm and the serum obtained was divided into several aliquots, and stored at −80°C until the time of assay.
The complete blood picture was obtained using the Pentra –80 automated blood counter (ABX, Montpellier, France).
Serum total IgE was determined using the solid phase enzyme-linked immunosorbent assay .
Principle: The IgE quantitative test kit is based on the solid phase enzyme-linked immunosorbent assay. The assay system utilizes one anti-IgE antibody for solid phase immobilization and another anti-IgE antibody in the antibody enzyme conjugate solution. The serum is added to the IgE antibody coated microtitre wells and incubated with the zero buffer. If human IgE is present in the serum, it will combine with the antibody in the wells. The wells are then washed to remove any residual serum, and IgE antibodies labeled with the conjugate are added. The conjugate will bind immunologically to the IgE in the wells, resulting in the IgE molecules being sandwiched between the solid phase and enzyme-linked antibodies. The kits are provided by Chemux Bioscience (S San Francisco, California USA).
Lactalbumin-specific and lactoglobulin-specific IgE were determined using a cellulose disc-based enzyme allergosorbent test .
Principle: The test is a cellulose disc-based enzyme allergosorbent test. The lactalbumin is attached to cellulose discs and an anti-human IgE antibody conjugated with alkaline phosphatase is used. The test sample is allowed to react with the lactalbumin cellulose discs. After incubation and washing, the substrate is added and dephosphorylated by the conjugated enzyme into a yellow product. The kit is provided by RIDASCREEN (Germany).
Colometeric determination of total plasma proteins  and albumin levels  was done at Diamond (Egypt).
The data collected were tabulated and analyzed using SPSS (Statistical Package for the Social Science software, SPSS Inc. Chicago, IL, USA) statistical package version 20 on an IBM compatible computer. Quantitative data were expressed as mean ± SD (X ± SD) and analyzed by applying the t-test for comparison between two groups of normally distributed variables, while for comparison between two groups of not normally distributed variables the Mann–Whitney test was applied. Qualitative data were expressed as number and percentage and analyzed by applying the c 2-test for a 2 × 2 table and if one cell had the expected number less than 5 then Fisher's exact test was applied. Spearman correlation was used for not normally distributed quantitative variables or when one of the variables is qualitative. The receiver operating characteristic curve was used to determine cutoff points, sensitivity, and specificity for quantitative variables of interest.
| Results|| |
The results of the present study are presented in [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6].
|Table 1 Statistical comparison of history and clinical data suggestive of cow milk allergy among the studied groups|
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|Table 2 Statistical comparison of laboratory parameters among studied groups|
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|Table 3 Diagnostic validity of total IgE, lactoglobulin-specific and lactoalbumin-specific IgE (IU/ml) in diagnosis of protein allergy cases|
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|Table 4 Diagnostic validity of combinations of specific IgE antibodies in diagnosis of protein allergy cases|
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|Table 5 Comparison of family history and history of symptoms suggestive of cow milk allergy in infants with total IgE-positive and negative cases|
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|Table 6 Comparison of laboratory investigations in infants with total IgE, lactoglobulin-specific and lactoalbumin-specific IgE positive and negative cases|
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The results showed no significant statistical difference between the two studied groups as regards age and sex distribution (not shown).
There was a significant statistical difference between the studied groups regarding family history, immediate, respiratory, and skin symptoms while there was no significant difference regarding breast feeding ([Table 1]).
There was a significant increase in white blood cells (WBCs) count, eosinophil% total IgE, lactalbumin-specific IgE, and lactoglobulin-specific IgE in group 1 when compared with group 2. However, there was a significant decrease of hemoglobin and serum total proteins in group 1 when compared with group 2 and no significant statistical difference regarding other parameters ([Table 2]).
The diagnostic accuracy of using total IgE in diagnosis of cow milk protein allergy was 59%, with sensitivity of 44%, specificity of 95%, positive predictive value of 96%, and negative predictive value of 40% at the cutoff point of 50.05 IU/ml. The diagnostic accuracy of using lactoglobulin IgE in diagnosis of cow milk protein allergy was 84%, with sensitivity of 78%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 65% at the cutoff point of 0.345 IU/ml. The diagnostic accuracy of using lactoalbumin IgE in diagnosis of cow milk protein allergy was 83%, with sensitivity of 84%, specificity of 80%, positive predictive value of 91%, and negative predictive value of 67% at the cutoff point of 0.335 IU/ml ([Table 3]).
The diagnostic accuracy of total IgE and lactoglobulin combined was 77% with sensitivity of 88%, specificity of 50%, positive predictive value of 81%, and negative predictive value of 63%, the diagnostic accuracy of total IgE and lactalbumin combined was 76% with sensitivity of 92%, specificity of 35%, positive predictive value of 78%, and negative predictive value of 64%, the diagnostic accuracy of lactoglobulin IgE and lactalbumin combined was 87% with sensitivity of 90%, specificity of 80%, positive predictive value of 92%, and negative predictive value of 76%. However, the diagnostic accuracy of total IgE, lactoglobulin IgE, and lactalbumin combined was 76% with sensitivity of 92%, specificity of 35%, positive predictive value of 78%, and negative predictive value of 64% ([Table 4]).
There was a significant statistical difference between positive and negative cases of total IgE and lactoglobulin-specific IgE in infants suggestive of CMA regarding family history. However, there was a significant statistical difference between positive and negative cases of total IgE in infants suggestive of CMA regarding immediate symptoms and nonsignificant statistical difference regarding other parameters ([Table 5]).
There was a significant statistical difference between positive and negative cases of total IgE in infants suggestive of CMA regarding WBCs count, eosinophil%, lactoglobulin IgE, and lactalbumin IgE and a significant statistical difference between positive and negative cases of lactoglobulin IgE in infants suggestive of CMA regarding eosinophil% and total IgE, red blood cells count, and lactalbumin IgE. Also, there was significant statistical difference between positive and negative cases of lactalbumin IgE in infants suggestive of CMA regarding eosinophil%, total, IgE and lactoglobulin IgE while, other parameters show a nonsignificant statistical difference ([Table 6]).
| Discussion|| |
The prevalence of CMA in children living in the developed world is ˜2–3%, making it the most common cause of food allergy in the pediatric population .
Preterm infants are at an increased risk of death, acute and long-term morbidities often associated with nutritional compromise and impaired growth .
Specific IgE testing helps to confirm diagnosis in IgE-mediated allergy, and prick tests can be used to add value to the diagnosis . However, a combination of the two tests is not necessary for the diagnostic workup .
This study assesses the value of lactoglobulin-specific and lactoalbumin-specific IgE in diagnosis of CMA.
In the present study neither the age nor the sex were significant between patients and controls. This agreed with the studies of Castroa et al. , Wood et al. , Topal et al. , and Van den Hoogen et al. .
In the present study a positive family history of allergic diseases was present in 40% of cases. This is also significant in relation to lactoglobulin-specific IgE and total IgE.
This agreed with the study of Sommanus et al.  who found that 52% of parents had atopic diseases. However, the study of Mowszeta et al.  stated a positive family history of allergy in only 11% of parents.
A genetic basis for atopic disease is supported by twin studies which show that allergies such as asthma, eczema, and hay fever correlate more highly in monozygotic than dizygotic twins irrespective of whether the monozygotic twins were raised together or apart .
Allergic disorders were a common association in common variable immunodeficiencies patients, noted in 35% of cases, including allergic rhinitis, asthma, eczema, and food allergies .
CMA can induce a diverse range of symptoms of variable intensity in infants. It is helpful to differentiate between the 'immediate' (early) reactions and 'delayed' (late) reactions. Immediate reactions occur from minutes up to 2 h after allergen ingestion and are more likely to be IgE mediated, whereas delayed reactions manifest up to 48 h or even 1 week following ingestion. Combinations of immediate and delayed reactions to the same allergen may occur in the same patient .
In the current study the presence of respiratory symptoms is seen in 36% of cases. The immediate symptoms and the skin symptoms were present in 48 and 54% of cases respectively.
This is in accordance with the studies of Skripak et al. , Vandenplas et al. , Sommanus et al. , Wood et al. (2013) , and Van den Hoogen et al.  who stated that, the most common presenting symptoms of milk allergy were skin-related reactions. In contrast to the present study Merras-Salmio et al.  found that skin symptoms were nonsignificant and this may be due to the fact that the study focused mainly on non-IgE-mediated milk allergy.
In the current study the history of breast feeding was 52% with nonsignificant relation to total IgE, lactoglobulin-specific IgE, and lactalbumin-specific IgE. This matched with the study of Skripak et al. . In contrast the study of Sommanus et al. (2013)  found that the mean age of ceasing breast feeding only was 1.9 months, while that of starting CM formula was 1.5 months. So, exclusive breastfeeding has been shown to be the best method to prevent allergy .
In the current study the WBCs and eosinophil% were significantly increased in the patients group compared to controls. WBCs count significantly increased in cases with positive total IgE. The eosinophil% significantly increased in cases with positive total IgE, lactalbumin-specific IgE, and lactoglobulin-specific IgE. This agreed with studies of Sommanus et al.  and Beşer et al. .
In the current study the total IgE level was significantly increased in the patients group when compared with controls with a mean of 86.53 ± 1.23 IU/ml. The cutoff value was 50.05 with sensitivity of 44% and specificity of 95%, positive predictive value of 96%, negative predictive value of 40%, and diagnostic accuracy of 59%.
In the present study the cutoff point of lactoglobulin-specific IgE was 0.345 IU/ml with sensitivity of 78% and specificity of 100%, the positive predictive value is 100%, the negative predictive value is 65%, and the diagnostic accuracy is 84%. The cutoff point of lactalbumin-specific IgE is 0.335 IU/ml with sensitivity of 84% and specificity of 80%, the positive predictive value is 91%, the negative predictive value is 67%, and the diagnostic accuracy is 83%.
This agreed with the study of Skripak et al. , Ahrens et al. , Keet et al. , and Sommanus et al.  in which IgE-mediated disease was defined as having a skin prick test with a wheal diameter of 3 mm and/or a cm (for cow milk) for IgE concentration of 0.35 IU/ml.
In contrast the study of Castroa et al.  stated that the best specific IgE concentrations found were: 3.06 IU/ml for whole milk, 2.08 IU/ml for lactalbumin, 1.85 IU/ml for lactoglobulin, and 1.47 IU/ml for casein. This difference may be because this study included 123 children with confirmed CMA and the present study included only 50 children with suspected CMA.
Also, this was in contrast to the study of Bellini et al.  in which the determination of cow milk specific IgE was performed and values greater than 0.10 IU/ml were considered as positive.
In the present study the diagnostic validity of combined levels of total IgE and specific IgE showed that the combination of lactalbumin-specific and lactoglobulin-specific IgE was the best as sensitivity was 90%, specificity was 80%, positive predictive value was 92%, negative predictive value was76%, and diagnostic accuracy was 87%.
| Conclusion|| |
Lactalbumin-specific and lactoglobulin-specific IgE are important in diagnosis of cow milk protein allergy and their combination may give better diagnostic accuracy. Total IgE has lesser diagnostic use in milk protein allergy. The levels of lactoglobulin-specific and lactalbumin-specific IgE are related to family history, immediate symptoms, and eosinophil%.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]