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Analysis of Acceptance of Cow Milk-Free Food by Allergic Children
Marilia Porto Oliveira Nunes*1,2, Francisca Neila Maranhão Cândido1, Natália De Macedo Vieira1 and Júlio César Chaves Nunes Filho3
1 University of Fortaleza, UNIFOR, Brazil
2Christus University Center, Brazil
3Federal University of Ceará, Brazil
Submission: January 09, 2020; Published: February 25, 2020
*Corresponding author: Marilia Porto Oliveira Nunes, Rua Luiza Miranda Coelho, 603, apt 203, CEP 60.811-110 Fortaleza, Brazil
How to cite this article: Marilia Porto Oliveira Nunes, Francisca Neila Maranhão Cândido, Natália De Macedo Vieira, Júlio César Chaves Nunes Filho. Analysis
of Acceptance of Cow Milk-Free Food by Allergic Children. Nutri Food Sci Int J. 2020. 9(4): 555770.
Objective: To analyze foods free from cow's milk protein by allergic children. Methods: The research for the development of the project, regarding the objectives, was exploratory, as to the nature, applied and the procedures, a case study. It was held at the Integrated Medical Care Center (NAMI), from February to April 2017, in the population of children from two to five years old with cow's milk protein allergy. We used forms with hedonic facial expression scale with five categories to be selected according to the children's acceptability. The research was designed according to what governs Resolution 466/12 of the National Health Council (BRASIL, 2012).
Results: In the study we obtained 14 children and 14 participating mothers. We found that children aimed only at the taste of the products, with product A (salty barbecue flavored product) being the most acceptable with 79% acceptance, unlike mothers who generally exploited the product from the ingredients mentioned in label up to its nutritional value, always comparing with conventional products. The most acceptable product among mothers was product C (Sweet product, similar to conventional cornstarch cookies), with 71% acceptance. Conclusion: The research result provided information that contributed to the quality of life of children with APLV, considering that they can have a balanced, varied and enjoyable diet.
Among food allergies, the most common is milk protein allergy, affecting mainly children from 0 to 24 months. The allergic cycle is developed when milk protein is identified as a foreign agent in the body .
The actual prevalence of aplv in the general population is still unknown. In children, cow's milk protein allergy is manifested in about 2% to 7.5% in the first years of life .
Aplv symptoms may be immediate (ige-mediated) or late (non-ige-mediated), depending on the type of reaction triggered, and are divided into four groups: ige-mediated or type i hypersensitivity; cytotoxicity or type ii; by immunocomplexes or type iii and cellular or type iv .
The main clinical manifestations of aplv are: irritability, crying and difficulty in weight gain. It usually involves the following systems: cutaneous, gastrointestinal, respiratory and cardiovascular. In cutaneous manifestations, urticaria (lesions lasting up to 6 weeks) and angioedema are the most common.
Gastrointestinal symptoms usually occur shortly after eating or within two hours of eating, namely: abdominal distention, nausea, vomiting, diarrhea and melena. Respiratory system symptoms are associated with skin and gastrointestinal symptoms, causing a sore throat, irritating dry cough, intense nasal congestion, sneezing, asthma, and rhinitis secondary to cow's milk intake or inhalation .
For a reliable diagnosis of APLV, a detailed history and physical examination is essential. In the anamnesis, it is important to investigate the food history, in order to collect information about the diet from the first months of life to the present age, record when the allergy began, the frequency of symptoms, the factors and individual characteristics of the patient, what is the amount and shape of the potential food that causes the allergy. Physical examination, besides providing anthropometric data, is fundamental to evaluate signs that may be related to APLV .
The treatment of APLV is based on a diet excluding cow's milk and dairy products, which aims to prevent possible symptoms and improve the child's quality of life, growth and proper
development. In cases of acute allergic crisis or chronic signs,
treatment becomes drug .
Currently, it is observed that the number of people who are
allergic to cow's milk protein has been increasing, because of this,
the search for products that favor the health and well-being of this
public has been increasing. New products have been launched in
the market for the public with food allergies. Amaranth grain is
one of them, being characterized by a high protein, fat and mineral
content compared to conventional cereals. Amaranth leaves can
be used in salad production, and can be substituted for soups,
fillings, instant and infant products. The flour form is used in
pancakes, bread, tortillas and porridge, including beverages that
are similar to cow's milk . The treatment of APLV is based on
the total exclusion of cow's milk protein from the allergic diet. For
this, a balanced and sensorially pleasing diet should be developed
that meets the nutritional needs, especially when it comes to
children, so that they may develop normally
Traditionally, various products, such as cakes, cookies and
breads, are made with cow's milk. In the food market there are
similar products that are free from cow's milk protein. Thus, the
objective of this study was to analyze the acceptability of products
free of cow's milk by allergic children.
This is a cross-sectional and analytical study with a
The study was performed at the Integrated Medical Care
Center (NAMI), located in the city of Fortaleza in the Edson
The Center for Integrated Medical Care of the University
of Fortaleza has integral care with the human being, as well as
offering health services also has as its main objective to promote
quality of life. For this, they bring together professionals and
students in a modern and multidisciplinary structure, focused on
humanization and the evolution of care, always in line with the
academic research developed at the University.
Created in 1978, NAMI is proud to be a reference in the
North and Northeast for the quality and differential of medical
care provided, which includes services of a secondary nature
and, in some cases, even of high complexity. More than 300,000
procedures are performed per year, benefiting about 25,000
patients. NAMI care ranges from medical appointments,
laboratory testing, and immunization to specialized imaging,
nursing, nutrition, psychology, physiotherapy, and speech
therapy, social work, and occupational therapy services. Besides,
of course, several groups that deal with topics such as mental
health, climacteric, stretching, monitoring pregnant women,
among others. The Integrated Medical Care Center (NAMI) has
been conducting a Cow Milk Protein Allergy (APLV) program
since 2014, and childcare is provided to the following health
professionals: Gastropediatrician, Allergologist and Nutritionist.
The population chosen was the universe of 180 children
participating in the NAMI APLV group. The inclusion criteria
were children who had a protein allergy to cow's milk and were
between two and five years old, and as an exclusion criterion. ,
children who had lactose intolerance and were older than 5 years.
The invitation to participate in the research was made when the
groups were meeting at NAMI, where the researchers personally
explained the benefits of the study and invited them to participate.
Thus, the sample selected all children between two and five
years old who had cow's milk protein allergy and their guardians
who attended the waiting room for the nutritional care of the
group with APLV. Children allergic to cow's milk protein who
were lactose intolerant and older than 8 years were excluded
from the study. The database currently has 28 participants, but
research is still ongoing. Prior to the data collection process, cow's
milk protein-free products were evaluated as follows: Analysis of
label ingredients, similarity analysis with conventional products
and taste. The brands chosen were: ‘Liane’, ‘Xilitoca’ and ‘Mother
All products were carefully chosen, seeking to maintain
nutrients and other important characteristics such as fresh foods,
for the proper functioning of the body.
Data collection was carried out from February to April 2017.
Each participant signed the informed consent form and then
filled out the form and were interviewed. The form contained
identification questions for the participating child and his / her
The data of the child and guardian were collected in Part I of
the form, which contained information such as: Socioeconomic;
Blood type; If you had another type of allergy; Sex; Age; Family
data and school data. To perform the sensory analysis, Part II
of the same form was used, which has a hedonic scale of facial
expression, which was assigned the following values: 1- I hated
it, 2 - I didn't like it, 3 - both makes, 4 - liked and 5 - loved it.
Form III asked five questions about the daily food intake of family
members. In the test, the child and his guardian received samples
of the products, followed blindly. The hedonic scale was marked
by the children and their guardian with the help of two trained
analysts, so as not to induce and / or interfere with the study
participants' responses. For the presentation of the products was
made available, in a container, one unit of each selected product.
The samples were used in the same order for all participants.
After ingestion, each child and responsible participant marked
on the hedonic scale the facial expression that best represented
their opinion regarding the tasted food. Between the tasting of the
samples, the children ingested at least 50ml of water. Rinsing the
mouth between samples is important so that the residual flavor is restricted and does not interfere with the evaluation of the next
The products tested were selected by the company "Zero%
cow's milk", which provided the food products used in the
research, with the supervision of the researchers. Sweet and
salty cookies were selected, among them: Product A - Salted
Cracker Biscuit (Barbecue Flavor); Product B - Tapioca Biscuit
(Salty Flavor); Product C - Sweet Cookie (Similar to conventional
cornstarch) and Product D - Red Fruit Cookies (Sweet flavor).
Fourteen children participated in the study in question, 36%
(5) female and 64% (9) male. The average age of participants
ranged from 2 to 5 years, with 57% being children from 2 to 3
years old and 43% from 4 to 5 years old. As for blood type 36%
(5) have O + blood and 64% (9) did not report. As for other
allergies, 64% of children had other allergies and only 36% did
not. Regarding socioeconomic status, 36% (5) of the families had
an income of one to five minimum wages (Table 1).
The results of this study showed that of the 14 children
evaluated, most were between 2 and 3 years old and were males
with 9.64%, while females were 5.57%. The sample is mostly
composed of middle- or lower-class people. From the study, we
also observed that food allergy in one family member directly
influences changes in eating habits of other family members
All the children tasted all the products, having varied
acceptance, according to their individuality, so that some showed
to like the sweet products more and the salty ones.
Sweet-flavored products had better acceptance than
salty-flavored products, as these products are more similar to
conventional products (Table 2).
The foods that made up the sensory analysis were chosen to
take into account the newest products similar to those already
on the market. Only product B (Tapioca cookie) was rated as
loathed, with a percentage of 7%. Product A (Salted Cracker
Cracker - Barbecue Flavor) and Product D (Red Fruit Cookies -
Sweet Flavor) were rated as 'whatever', both with a percentage of
7%, not providing significant information for product evaluation.
Adding the percentage obtained in all available products, 64% of
the evaluated did not like them. Of the four products evaluated,
79% of children liked product A (Cracker Salted Cracker -
Barbecue Flavor), 36% liked product B (Tapioca Cracker),
50% liked product C (Sweet Cracker - Similar to conventional
cornstarch) and 71% enjoyed the product D (Red Fruit Cookies
- Sweet Flavor). Taking into account the taste, these products are
very similar to conventional products, thus justifying their good
acceptance (Table 3).
The products that were rated “Loved” were as follows: 7%
of product A (Cracker Salted Cracker - Barbecue Flavor); 7% of
product B (Tapioca cookie); 43% of product C (Sweet cookie -
Similar to conventional cornstarch) and 29% of product D (Red
fruit cookies - Sweet flavor). Ratifying the greater acceptance of
sweet tasting products.
In the mothers' forms, the products that were evaluated as I
loved them were: Product A (Salted Cracker Cracker - Barbecue
Flavor) with 14%; Both products C (Sweet cookie - Similar to
conventional cornstarch) and D (Red Fruit Cookies - Sweet flavor)
resulted in 29%.
The products evaluated as “Likes” were as follows: 64% of
product A (Cracker Salted Cracker - Barbecue Flavor); 50% of
product B (Tapioca cookie); 71% of product C (Sweet cookie -
Similar to conventional cornstarch) and 64% of product D (Red
fruit cookies - Sweet flavor).
Products rated “Disliked” yielded the following results: Both
A (Cracker Salted Cracker - Barbecue Flavor) and D (Red Fruit
Cookies - Sweet Flavor) products achieved 7%. Already the
products evaluated as “detested” had as results: 14% of product
A (Cracker Salted Cracker - Barbecue Flavor) and 50% of product
B (Tapioca Cracker).
In the analysis of the evaluation of the mothers, it was
observed that the products have a good acceptance by most of
them, because in the hedonic scale classification were found
higher rates of "liked" and "loved". This may be justified because
unlike children, who are only aware of tasty foods, mothers
also realize the benefits that food brings to health. There were
reports of mothers who liked the products because, besides being
tasty, having enough nutrients, in order to help the growth and
development of the child aligned with a similar diet to other
family members (Table 4).
Statistical tests were performed using the Turkey, Chi-Square
programs, but their results were not considered relevant to the
research because the N that participated was small to obtain
In recent decades, there have been several studies showing
that allergic diseases are significantly influencing the quality of
life not only of allergic patients, but also of their families and close
friends . In the study analyzed, it was observed that changes
in the eating habits of allergic people influenced the other family
members, since there is greater care in food to avoid exposure to
foods that aggravate the allergic condition.
There are several factors that affect allergic people, the
most common being anxiety and stress, which can impair their
cognitive ability and their social environments, resulting in
behavioral problems and school development. Dining out is still
a factor avoided by parents of children. Activities such as: Going
to birthday parties; Playing at friends' houses are examples of
some activities that are generally restricted in the daily lives of
allergic children, leading to a social withdrawal from them . We
identified through the reports on the forms that mothers prepare
their children's meals to eat outside the home, in environments
ranging from school to festive and travel, being a positive habit
in the lives of children, because their social environment is
Parents of allergic children carry concerns in their daily lives
regarding the proper nutrition of their children. The entire process
of purchasing, preparation, ingredient checking of products, high
cost prices, require planning to meet all the nutritional needs of
the child. In most cases, the mother's quality of life is most affected
because she is responsible for performing all these tasks . In
our research, the report of mothers is similar to what was said by
the author, since since the discovery of allergy in their children,
their lives are moved primarily to fulfill all these functions with
the main goal of the welfare of their children, ie , the quality of life
of mothers becomes irrelevant to them, because what they really
put first is their children. However, through all this food planning
of the allergic child, mothers are positively influenced in relation
to their eating habits, because through the knowledge they
acquire in all planning they make healthier choices in their meals.
Cow's milk is the food that is often consumed on a daily basis,
as it can make up every meal, for this reason, cow's milk allergy
is evident today, about 270 billion liters of milk. It is consumed
worldwide . In the study carried out, the chosen audience was
with children who had been allergic to cow's milk protein since
birth, so frequent consumption of cow's milk was not the reason
why the children in this study had the onset of allergy.
About 170 foods have been listed as causing food allergy.
However, eight main ingredients that cause the most food allergies
stand out: milk, fish, eggs, nuts, wheat, crustaceans, peanuts and
As a result of food reactions, it generates restrictions and, as a
result, allergic individuals need greater care in choosing the foods
to replace . In the study we evaluated through reports that
the behavior of parents facing the greatest restriction on food to
their children who are allergic to cow's milk protein, corresponds
to what the author says, because careful choice of these foods has
become a priority in life. from parents.
In the food market there are substitutes for dairy drinks
that are vegetable drinks, made with: oilseeds, legumes, cereals
and pseudo cereal, besides being industrially ready, can be
prepared by hand, although they may have limits in relation to the
characteristics. Sensory . There is also an option to replace
cow's milk, the almond-based drink. It is a drink rich in vitamins,
fiber and minerals, and can be found in an industrialized way,
but it is not accessible to low-income individuals, as it is a high
cost product . There is also rice-based drink, it has low cost,
however, it is noteworthy that the glycemic index of rice-based
drink is high when compared to cow's milk. Thus, it is essential
that its consumption is balanced, because in excess can cause the
emergence of chronic diseases, such as diabetes and obesity. Its
consumption is not recommended for children under one year16.
We identified from the reports of mothers that the products used
in sensory analysis and the others that are available in the market
for the public with APLV are aware of them, but report that there
are few stores that sell these products, becoming less accessible
to any of them.
One of the most commonly found foods in the market as
a replacement for cow's milk is soybeans, but studies report
that 60% of people who have allergies to cow's milk also have
coincidental reactions to soybeans. It is even more difficult to find
substitute foods . In the study population there were some
children who, besides being diagnosed with a cow's milk protein
allergy, also had soy allergy, so finding foods that can replace
cow's milk for this public may be less accessible.
Based on what was discussed, it can be concluded that the
products used in the sensory analysis had a good acceptability of the
participants. It was observed that the children analyzed positively
by the question of the taste of the products, as the mothers the
acceptability was also positive, because they reported that the
products were sensorial similar to the conventional products in
the market. Parents of children with a cow's milk protein allergy
become hypervigilant and careful about feeding them to avoid any
contact with foods containing cow's milk protein. In view of this,
the demand for foods aimed at this public grows more and more,
however, accessibility is still a problem, since there are few stores
that sell these products. Given the results, the study was important
because it was sensorially analyzed alternative products, which
are free of cow's milk, noting the acceptability by the public and
the financial conditions of the families of the research participants
to purchase them.