Amino acid formula as a new strategy for diagnosing cow’s milk allergy in infants: is it cost-effective?

Figures & data

Figure 1. Decision tree showing the strategy used to manage infants suspected of having a cow’s milk allergy according to the Brazilian Food Allergy Guidelines and the new strategy, which used an amino acid formula in the diagnostic elimination diet.

Table 1. Clinical and epidemiological data used to construct the decision model.

Parameter	Value	Reference
Incidence of infants with suspected CMA	6.7/100 infants/year	^21
Incidence of infants with confirmed CMA	2.2/100 infants/year	^21
Breast feeding in infants with CMA	23%	^21
Age at model admission
<6 months	50%	^22
6–24 months	50%
Formula success rate
Amino acid	100%	^8^,^9^,^12^,^18^,^19^,^23^,^24
Extensively hydrolyzed	90%	^10^,^12^,^25–28
Soy	86%	^12^,^13^,^29–31
Development of oral tolerance to cow’s milk protein
At 12 months	56%	^21
At 24 months	77%
Proportion of IgE-mediated CMA	54%	^21
Proportion of children with a confirmed CMA  diagnosis after the challenge test	50%	^18^,^32

CMA, cow’s milk allergy.

Table 2. Unit resource costs (Currency: Brazilian real, 1 R$= 2.3 US dollars).

Resource	Resource use	Total cost
Amino acid formula	<6 months (2.1 cans/week)	R$349.80/week^a
	>6 months (1.6 cans/week)	R$266.51/week^a
Extensively hydrolyzed formula	<6 months (2.1 cans/week)	R$178.88/week^a
	>6 months (1.6 cans/week)	R$136.29/week^a
Soy formula	>6 months (1.6 cans/week)	R$29.60/week^a
Medical consultations	Symptomatic (2/month) (expert panel’s opinion)	R$20.00/month^b
	Asymptomatic (1/month) (expert panel’s opinion)	R$10.00/month^b
Oral food challenge under medical supervision at the hospital	100% of oral food challenge tests according to the expert panel’s opinion and the Brazilian guideline recommendations	R$190.52^b
Specific IgE to cow’s milk protein	54.0% of the patients (incidence of IgE-mediated food allergy)^19	R$1.77^b
Colonoscopy	1.8% of patients with no clinical improvement after the first 6 weeks on an elimination diet (expert panel’s opinion)	R$122.66^b
Barium contrast radiography of esophagus, stomach, and duodenum	10.0% of patients with no clinical improvement after the first 6 weeks on an elimination diet (expert panel’s opinion)	R$35.22^b
Drugs for vomiting and gastroesophageal reflux^4	53.5% (symptomatic patients with vomiting and esophageal reflux)^10	R$6.83 (<6 months) and R$11.41 (>6 months)^c
Drugs for atopic eczema^5	18.2% (symptomatic patients with cutaneous symptoms)^10	R$3.62 (<6 months) and R$3.62 (>6 months)^c

^a The purchase price in regular public tender.

^b SIGTAP: Management system for drugs and procedures, SIFTAP-SUS³³.

^c Health cost bank (BPS) by the Ministry of Health³⁴.

^d Domperidone (2.5 ml/10 kg, 3 times/day), Ranitidine (4 mg/kg, 2 times/day).

^e Hydrocortisone acetate and hydroxyzine (0.7 mg/kg, 3 times/day).

Table 3. Cost-effectiveness according to the mean of the cohort used in the model.

	Total costs (Brazilian real)	Symptom-free days until 36 months of age (days)
Current practice according to the Brazilian Food Allergy Guideline	R$3,641.08	875.7
New strategy using an amino acid formula in the diagnostic elimination diet	R$3,341.57	900.6
Incremental	− R$299.51	24.9

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