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Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5056 (Published 05 December 2018) Cite this as: BMJ 2018;363:k5056

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Re: Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers

I agree with many of Dr van Tulleken's highlighted concerns, but they merit some qualification. Colleagues have commented to me that many academic meetings are dependent on industry support; and paediatrics doesn't have the diversity of different pharmaceutical companies creating a balanced 'pharma-biome' in which to culture healthy relationships. That being said, I'd qualify the article to say that removing CMP from the diet is highly effective in certain situations (e.g. blood in the stool). I think it highlights the importance of integrating guidelines so they say the same message e.g. NICE food allergy, and GORD in children (NG1) and constipation (CG99 - neither are mentioned in the article) and having a corpus of guidance, rather than free-standing guidelines which may be more prone to being influenced.

I note the absence of voices (either patient or clinician) taken from outside the M25. In the absence of a definitive test, and a burden of disease, the importance of maintaining parental confidence in breastfeeding even if on a CMP free diet, walking that difficult journey with parents, and supporting their choices with information is key: within the multidisciplinary team (including health visitors and dieticians). These families rarely have 1 symptom in isolation, (e.g. reflux+family history of CMP+eczema) for clinicians to start off with an exclusion diet and you'll be able to give families an idea of how likely an exclusion diet will work (e.g. only 10% patients benefit from an exclusion diet in isolated constipation).

I hope that reflects the pragmatic approach taken outside certain specialist centres, and the efforts we take in improving parental confidence.

Competing interests: NICE fellow and contributor to NG1: NIGE guidelines for GORD in children

11 December 2018
Mark Tighe
Consultant Paediatrician
Poole Hospital
Poole Hospital