The prevalence and natural course of food protein–induced enterocolitis syndrome to cow’s milk: A large-scale, prospective population-based study

Natural history of food protein-induced enterocolitis syndrome

PURPOSE OF REVIEW

Because of the paucity of reports and variability in the diagnostic criteria utilized, little is known regarding the natural outcome of patients with food protein-induced enterocolitis syndrome (FPIES). Data extracted from referenced manuscripts, as well as allergists' unpublished observations from across the globe, were used to form a cohesive opinion regarding its natural outcome.

RECENT FINDINGS

All authors concur that there is a generally high rate of recovery for FPIES. The most common foods causing FPIES are milk and soy. Depending upon which study is analyzed, by the age of 3-5 years, approximately 90% of patients recover from their disease. Recovery from FPIES to solid foods, occurs at a later age, but may reflect a later stage of introduction of the food into the diet. An important clinical outcome, although not common, is a shift from FPIES food hypersensitivity to an IgE-mediated food allergy. This necessitates a change in the oral food challenge protocol, if IgE-mediated sensitization is detected.

SUMMARY

Over the past several years, there has been an increasing awareness of FPIES. This knowledge should lead to a more timely diagnosis and should reassure parents and practitioners alike regarding its favorable course.

Clinical features and resolution of food protein-induced enterocolitis syndrome: 10-year experience

BACKGROUND

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy. FPIES diagnosis is frequently delayed because of the absence of classic allergic symptoms and lack of biomarkers.

OBJECTIVE

We sought to characterize the clinical features and resolution of FPIES in patients evaluated in our practice.

METHODS

Subjects 6 months to 45 years of age with FPIES were prospectively recruited for oral food challenges (OFCs). Medical records were searched to identify the subjects who did not participate in OFCs.

RESULTS

Among 160 subjects, 54% were male; median age at diagnosis was 15 months. We performed 180 OFCs to 15 foods in 82 subjects; 30% of the study population had FPIES confirmed based on OFC results. The most common foods were cow's milk (44%), soy (41%), rice (22.5%), and oat (16%). The majority (65%) reacted to 1 food, 26% reacted to 2 foods, and 9% reacted to 3 or more foods. The majority were atopic, and 39% had IgE sensitization to another food. Thirty-nine (24%) subjects had positive specific IgE levels to the food inducing FPIES. Among children with specific IgE to cow's milk, 41% changed from a milk FPIES to an IgE-mediated phenotype over time. The median age when tolerance was established was 4.7 years for rice, 4 years for oat, and 6.7 years for soy. Median age when milk tolerance was established for subjects with undetectable milk-specific IgE levels was 5.1 years, whereas none of the subjects with detectable milk-specific IgE became tolerant to milk during the study (P = .003).

CONCLUSION

FPIES typically resolves by age 5 years. Milk FPIES, especially with detectable food-specific IgE, can have a protracted course and eventually transition to acute reactions.

Friend or foe? Figuring out the difference between FPIES, IgE-mediated allergy and food intolerance

Most physicians recognise the severe nature of the anaphylactic reactions associated with IgE-mediated food allergy. Adverse reactions to food involving non-IgE mechanisms are often less well understood and are often not diagnosed. Food protein-induced enterocolitis syndrome (FPIES) is an example of a severe non-IgE immune-mediated food reaction that is part of a spectrum of what is believed to be T-cell-mediated reactions. FPIES results in excessive emesis and diarrhoea hours after ingestion of the offending food. While common triggers include milk, soy, wheat and oat, some children may have multiple triggers, leading to malnutrition from lack of food options and unusual developmental concerns related to food aversion.

Markers of gut mucosal inflammation and cow's milk specific immunoglobulins in non-IgE cow's milk allergy

Background

Allergy to cow’s milk protein (CMP) may cause gastrointestinal (GI) symptoms in the absence of CMP specific IgE. The immunological mechanisms involved in such disease are not fully understood. Therefore we examined markers of gut mucosal inflammation and the immunoglobulin profiles in children with Gl symptoms suspected of cow’s milk protein allergy (CMPA).

Patients and methods

We prospectively recruited infants and young children (n = 57; median age 8.7 months) with gastrointestinal complaints suspected of CMPA. The diagnosis of CMPA was made using the double-blind, placebo-controlled food challenge. Serum and stool samples were collected during CMP-free diet and after both placebo and active challenges. We analyzed the stool samples for calprotectin, human β-defensin 2 and IgA. In serum, we analyzed the levels of β-lactoglobulin and α-casein specific IgA, and IgG antibodies (total IgG and subclasses IgG1 and IgG4). Control group included children with e.g. dermatological or pulmonary problems, consuming normal diets.

Results

Fecal calprotectin levels were higher in the challenge positive group (n = 18) than in the negative (n = 37), with respective geometric means 55 μg/g [95% confidence interval 38–81] and 29 [24–36] μg/g (p = 0.0039), during cow’s milk free diet. There were no significant inter-group differences in the fecal β-defensin and IgA levels. The CMP specific IgG and IgA were not elevated in patients with CMPA, but the levels of β-lactoglobulin-IgG4 (p = 0.0118) and α-casein-IgG4 (p = 0.0044), and total α-casein-IgG (p = 0.0054) and -IgA (p = 0.0050) in all patient samples (regardless of CMPA diagnosis) were significantly lower compared to the control group using dairy products.

Conclusions

Despite cow’s milk elimination in children intolerant to cow’s milk there might be ongoing low-grade inflammation in the gut mucosa. CMP specific IgG or IgA should not be used to diagnose non-IgE CMPA. The observed frequency of impaired CMP specific total IgA, IgG and IgG4 production in patients following cow’s milk free diet warrants further studies.

Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment

This review focuses on advances and updates in the epidemiology, pathogenesis, diagnosis, and treatment of food allergy over the past 3 years since our last comprehensive review. On the basis of numerous studies, food allergy likely affects nearly 5% of adults and 8% of children, with growing evidence of an increase in prevalence. Potentially rectifiable risk factors include vitamin D insufficiency, unhealthful dietary fat, obesity, increased hygiene, and the timing of exposure to foods, but genetics and other lifestyle issues play a role as well. Interesting clinical insights into pathogenesis include discoveries regarding gene-environment interactions and an increasing understanding of the role of nonoral sensitizing exposures causing food allergy, such as delayed allergic reactions to carbohydrate moieties in mammalian meats caused by sensitization from homologous substances transferred during tick bites. Component-resolved diagnosis is being rapidly incorporated into clinical use, and sophisticated diagnostic tests that indicate severity and prognosis are on the horizon. Current management relies heavily on avoidance and emergency preparedness, and recent studies, guidelines, and resources provide insight into improving the safety and well-being of patients and their families. Incorporation of extensively heated (heat-denatured) forms of milk and egg into the diets of children who tolerate these foods, rather than strict avoidance, represents a significant shift in clinical approach. Recommendations about the prevention of food allergy and atopic disease through diet have changed radically, with rescinding of many recommendations about extensive and prolonged allergen avoidance. Numerous therapies have reached clinical trials, with some showing promise to dramatically alter treatment. Ongoing studies will elucidate improved prevention, diagnosis, and treatment.

Impact of cow's milk allergy on enterocolitis associated with Hirschsprung's disease

PURPOSE

To investigate the impact of cow's milk allergy (CMA) on infants with Hirschsprung's disease (HD).

METHODS

Twenty-four patients, who developed gastrointestinal symptoms before the age of 60 days and underwent surgery for HD in the period between January 2003 and December 2012, were enrolled in this study. They were divided into two groups based on CMA-related findings: stimulation index of lymphocyte stimulation test >300 % and the presence of eosinophilic infiltration in the resected colon. Ten patients were determined specimen as not having CMA (Group A), because they did not satisfy any of the criteria. The remaining 14 were determined as having possible CMA (Group B), because they satisfied either or both findings. Patient background characteristics, pre- and postoperative clinical history, and laboratory data were compared between Groups A and B.

RESULTS

Pre- and postoperative enterocolitis did not occur in Group A patients. Postoperative enterocolitis was more frequent in Group B than in Group A (p = 0.04). Other clinical and laboratory data did not show significant difference between the two groups.

CONCLUSION

CMA is a possible risk factor for postoperative enterocolitis in patients with HD.

Paediatric GI emergencies

Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.

Cow's milk-associated gastrointestinal symptoms evaluated using the double-blind, placebo-controlled food challenge

OBJECTIVE

The aim of this study was to evaluate the suspicion of cow's-milk allergy in infants with unspecific gastrointestinal (GI) symptoms using the double-blind, placebo-controlled food challenge.

METHODS

A prospective cohort study, which recruited 57 consecutive children with gastrointestinally manifested symptoms suspected of cow's-milk allergy. All patients underwent a 5-day double-blind, placebo-controlled food challenge for cow's milk.

RESULTS

The median age of the patients was 8.7 months. None had measurable cow's-milk-specific IgE. The food challenge was positive in 18 (32%) cases, with symptoms manifesting within 48 hours in 17 of 18 cases. The only symptom that correlated with the positive challenge was loose stools, reported as a presenting symptom in 78% of challenge-positive and in 46% of challenge-negative children (P = 0.043). During active challenge, the respective proportions were 82% and 2% (P < 0.0001). No serious adverse effects were manifested during the challenges. In the challenge-negative group, significant placebo reactions occurred in 18 (46%) patients. In the challenge-negative children, adult-type hypolactasia genotype CC frequency was higher (31%, P = 0.033) than national prevalence of 18%.

CONCLUSIONS

In an infant with unspecific GI symptoms suspected of cow's-milk allergy, this diagnosis is seldom confirmed. Other reasons for the troublesome GI symptoms should also be identified.

Gastrointestinal food allergy in infants

Food allergies are classified into three types, "IgE-mediated," "combined IgE- and cell-mediated" and "cell-mediated/non-IgE-mediated," depending on the involvement of IgE in their pathogenesis. Patients who develop predominantly cutaneous and/or respiratory symptoms belong to the IgE-mediated food allergy type. On the other hand, patients with gastrointestinal food allergy (GI allergy) usually develop gastrointestinal symptoms several hours after ingestion of offending foods; they belong to the cell-mediated/non-IgE-mediated or combined IgE- and cell-mediated food allergy types. GI allergies are also classified into a number of different clinical entities: food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctocolitis (FPIP), food protein-induced enteropathy (Enteropathy) and eosinophilic gastrointestinal disorders (EGID). In the case of IgE-mediated food allergy, the diagnostic approaches and pathogenic mechanisms are well characterized. In contrast, the diagnostic approaches and pathogenic mechanisms of GI allergy remain mostly unclear. In this review, we summarized each type of GI allergy in regard to its historical background and updated clinical features, offending foods, etiology, diagnosis, examinations, treatment and pathogenesis. There are still many problems, especially in regard to the diagnostic approaches for GI allergy, that are closely associated with the definition of each disease. In addition, there are a number of unresolved issues regarding the pathogenic mechanisms of GI allergy that need further study and elucidation. Therefore, we discussed some of the diagnostic and research issues for GI allergy that need further investigation.

Manifestations, diagnosis, and management of food protein-induced enterocolitis syndrome

CME EDUCATIONAL OBJECTIVES 1. Recognize manifestations, diagnosis, and management of food protein-induced enterocolitis syndrome (FPIES) in an outpatient setting. 2. Assess nutritional needs and provide anticipatory guidance for dietary management. 3. Recognize the indications of when to refer for assessment of resolution of FPIES using physician-supervised food challenges. Food protein-induced enterocolitis syndrome (FPIES) is an under-recognized non-immunoglobulin E (IgE)-mediated gastrointestinal food allergy affecting primarily infants and toddlers. An abnormal response to food antigen resulting in local inflammation is thought to lead to increased intestinal permeability and fluid shift. The primary features of acute FPIES are repetitive, projectile vomiting, lethargy, pallor, diarrhea, and dehydration. Chronic FPIES is typically seen in young infants with continued exposure to cow's milk or soy-based formula. Biomarkers are lacking and patients may undergo extensive workups for their symptoms, which often leads to a delay in diagnosis and puts infants at risk for feeding difficulties, nutritional deficiencies, and failure to thrive. This review will provide a guide in how to recognize the clinical features of and manage FPIES.

Guidance for the nutrition management of gastrointestinal allergy in pediatrics

Food allergies and their related elimination diets have been associated with an increased risk of inadequate nutrient intake and poor growth in the pediatric population. In recognition of these nutritional risks, the National Institute of Allergy and Infectious Diseases Guidelines for the Diagnosis and Management of Food Allergy in the United States recommend nutrition counseling and close growth monitoring for all children with food allergy. The care of children with gastrointestinal food allergic disorders can be complicated and is best performed with a structured approach in which medical and nutrition needs are addressed simultaneously. Children with gastrointestinal food allergy may be at greater nutritional risk because of decreased dietary intake. For these children, it is important to perform a comprehensive nutrition assessment to identify nutrition-related problems and to develop and implement a plan that meets the patient's needs within the context of the elimination diet. We provide an overview of the nutritional risks and strategies to assess nutritional status in pediatric patients with gastrointestinal food allergy.

Mislabelled cow's milk allergy in infants: a prospective cohort study

BACKGROUND

Although cow's milk allergy (CMA) is one of the most common food allergies, mislabelling non-allergic infants as being allergic to cow's milk is more common. Despite this, characteristics of families and infants with mislabelled CMA are lacking.

METHODS

Using a prospective population-based study, we identified infants with any possible adverse reaction to cow's milk (n=381) from a cohort of 13 019 infants followed from birth. They had a detailed history taken, skin prick tests and an oral food challenge when indicated. Infants with symptoms for which the causative relationship to cow's milk protein was excluded were compared with infants with IgE-mediated CMA and with a control group, and followed for 2-5 years.

RESULTS

Overall, 243 infants (1.87%) with mislabelled CMA were identified. Compared with 66 infants with IgE-mediated CMA, those with mislabelled CMA presented earlier and with symptoms usually involving a single organ system. Doctor-diagnosed atopic dermatitis (AD) was associated with mislabelled CMA (p<0.001), manifested primarily as skin rashes, compared with control infants. Higher maternal and paternal education were also associated with mislabelled CMA (p=0.007 and p=0.035, respectively) and manifested primarily as non-specific symptoms.

CONCLUSIONS

Mislabelled CMA typically presents within the first 3 months of life involving a single organ. Infant AD and higher parental academic education are associated with mislabelled reactions. Better parental and physician awareness of the importance of objectively diagnosing milk allergy is required to avoid mislabelling of infants as being allergic to cow's milk and to prevent potential nutritional deficiencies.

Practical approach to nutrition and dietary intervention in pediatric food allergy

Although the need for nutritional and dietary intervention is a common thread in food allergy management, the type of food allergic disorder and the identified food allergen will influence the approach to dietary intervention. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. However, dietary elimination in food allergy may also have undesirable consequences. Frequently, an elimination diet is absolutely necessary to prevent potentially life-threatening food allergic reactions. Allergen elimination can also ease chronic symptoms, such as atopic dermatitis, when a food is proven to trigger symptoms. However, removing a food with proven sensitivity to treat chronic symptoms may increase the risk of an acute reaction upon reintroduction or accidental ingestion after long-term avoidance, so it is not without risk. Additionally, it is not recommended to avoid foods in an attempt to control chronic symptoms such as AD and EoE when allergy to the specific food has not been demonstrated. Ultimately, allergen elimination goals are to prevent acute and chronic food allergic reactions in the least restrictive, but also the safest environment to supply a balanced diet that promotes health and growth and development in children.

Non-IgE-mediated gastrointestinal food allergies: distinct differences in clinical phenotype between Western countries and Japan

Non-IgE-mediated gastrointestinal food allergies, including food-protein-induced enterocolitis, enteropathy, proctocolitis and allergic eosinophilic gastroenteritis, seem to be increasing in several regions in the world. However, unlike the case of IgE-mediated food allergy, development of diagnostic laboratory tests and our understanding of the immunological mechanisms involved in non-IgE-mediated gastrointestinal food allergies lag. Although the clinical entities in Western countries have been well established, the clinical phenotypes might differ somewhat among the human races and geographical regions. In Japan, non-IgE-mediated gastrointestinal food allergies have increased sharply since the late 1990s, and clinicians have sometimes experienced confusion because of differences in the clinical phenotypes from those seen in Western countries. Aiming to solve this problem, we performed clinical research and determined a useful method for dividing patients into four clusters with distinctive clinical symptoms. We are confident this method will help in diagnosing and treating these patients. We also tried to clarify the differences between these patients in Japan and Western countries.

Pediatric allergy and immunology in Israel

After the geographic and sociodemographic settings as well as the health care in Israel are briefly described, the scope of pediatric allergy and immunology in Israel is presented. This includes specific disorders commonly encountered, the environment that induces symptoms, the specialists who treat them, and the common challenges of patients, parents, doctors, and allied health personnel who collaborate to manage the maladies and patient care. Allergies usually affect some overall 15-20% of the pediatric population. The main allergens are inhaled, ingested, or injected (insects stings). Generally, the incidence of the various allergens affecting children in Israel, is similar to other parts of the Western world. Owing to the high consanguinity rate in the Israeli population, the prevalence of the various immunodeficiency conditions (in the adaptive as well as the innate system) is higher than that reported worldwide. Pediatric allergists/immunologists also treat autoimmune disorders affecting the pediatric group. Pediatric allergy and clinical immunology are not separate specialties. The 25 specialists who treat children with allergic/immunologic diseases have undergone a basic training in Pediatrics. They also received an additional 2-yr training in allergy and clinical immunology and then have to pass the board examinations. They work mainly in pediatric allergy units, in several hospitals that are affiliated to the five medical schools in the country. Aside from clinical work, most of the centers are also heavily involved in clinical and basic research in allergy and immunology.

Cow's milk associated rectal bleeding: a population based prospective study

BACKGROUND

Isolated rectal bleeding in infants is often attributed to the consumption of cow's milk. However, the prevalence of this condition has not been described, and its preferred diagnostic methods and management are controversial.

METHODS

In a prospective population-based study following 13,019 children from birth, 21 infants with isolated rectal bleeding attributed to cow's milk protein consumption were identified. Following evaluation, parents were encouraged to resume cow's milk protein and infants were followed for reappearance of symptoms and thereafter for 6 yr. In addition, infants with rectal bleeding were compared to a control group of healthy infants.

RESULTS

The prevalence of isolated rectal bleeding attributed to cow's milk consumption was 0.16%. All infants were asymptomatic within days of dietary modifications. Eleven of the 14 infants (78.5%) whose parents reintroduced cow's milk protein to their diet following our evaluation tolerated it with no adverse effects. Those 11 infants were significantly younger at initial consumption of cow's milk protein (6.7 ± 1.6 months) compared to those who continued elimination diet (17.7 ± 9.2 months), (p = 0.002) while their 1-yr hemoglobin levels were comparable (p = 0.98). No risk factors for rectal bleeding were identified.

CONCLUSIONS

The prevalence of isolated rectal bleeding attributed to cow' milk is low. The condition is generally benign and resolves quickly with elimination diet. Reintroduction of cow's milk following resolution of symptoms is often well tolerated and is recommended for confirming the diagnosis and avoiding prolonged unnecessary elimination diets.

Clinical diagnosis and management of food protein-induced enterocolitis syndrome

PURPOSE OF REVIEW

To provide an overview of clinical manifestations, diagnosis and pathophysiology of food protein-induced enterocolitis syndrome (FPIES), an under-recognized and often misdiagnosed nonimmunoglobulin E-mediated food hypersensitivity. This review will highlight updates on natural history and clinical management.

RECENT FINDINGS

The main developments in FPIES involve epidemiology, common presentation and variants thereof, and natural history. Improved understanding and recognition of FPIES have influenced changes in clinical management.

SUMMARY

A large prospective population-based study reported cow's milk-FPIES cumulative incidence to be 0.34% by 1 year of age; immunoglobulin E-mediated cow's milk allergy was 0.5%. A case report has suggested that FPIES pathophysiology involves Th2 activation, and a shift away from Th2 signalling may be associated with resolution. Appreciation of the frequent incidence of multiple food-FPIES has influenced anticipatory guidance. Two case reports have described FPIES to food proteins in maternal breast milk. The threshold dose for FPIES reactivity may decrease with successive episodes. Reports from different populations indicate that children may outgrow FPIES sooner than previously thought.

Natural course and risk factors for persistence of IgE-mediated cow's milk allergy

OBJECTIVE

To describe the natural course of IgE-mediated cow's milk allergy (IgE-CMA) and to determine risk factors for its persistence in a population-based cohort.

STUDY DESIGN

In a prospective cohort study, 54 infants with IgE-CMA were identified from a population of 13 019 children followed from birth. Diagnosis of IgE-CMA was based on history, skin prick test (SPT), and an oral food challenge (OFC) when indicated. Allergic infants were followed for 48-60 months. Families were contacted by telephone every 6 months and asked about recent exposures to milk. OFC was repeated to evaluate for recovery. Clinical characteristics, SPT, and OFC outcomes were compared between infants with persistent IgE-CMA and infants who recovered.

RESULTS

Thirty-one infants (57.4%) recovered from IgE-CMA during the study period. Most infants (70.9%) recovered within the first 2 years. Risk factors for persistence on multivariate analysis included a reaction to <10 mL of milk on OFC (or on first exposure as estimated by the guardian, if OFC was not performed) (P = .01), a larger wheal size on SPT (P = .014), and age of ≤30 days at time of first reaction (P = .05).

CONCLUSIONS

Resolution occurs in most infants with IgE-CMA. Infants reacting to <10 mL of milk or in the first month of life, and those with a larger wheal size on SPT, are at increased risk for persistence.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2011

This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2011. Food allergy appears to be increasing in prevalence and carries a strong economic burden. Risk factors can include dietary ones, such as deficiency of vitamin D and timing of complementary foods, and genetic factors, such as filaggrin loss-of-function mutations. Novel mechanisms underlying food allergy include the role of invariant natural killer T cells and influences of dietary components, such as isoflavones. Among numerous preclinical and clinical treatment studies, promising observations include the efficacy of sublingual and oral immunotherapy, a Chinese herbal remedy showing promising in vitro results, the potential immunotherapeutic effects of having children ingest foods with baked-in milk if they tolerate it, and the use of anti-IgE with or without concomitant immunotherapy. Studies of allergic skin diseases, anaphylaxis, and hypersensitivity to drugs and insect venom are elucidating cellular mechanisms, improved diagnostics, and potential targets for future treatment. The role of skin barrier abnormalities, as well as the modulatory effects of the innate and adaptive immune responses, are major areas of investigation.

Four infants presenting with severe vomiting in solid food protein-induced enterocolitis syndrome: a case series

Introduction

Several different foods have been implicated in inducing the delayed and very significant vomiting and sometimes diarrhea that occurs in food protein-induced enterocolitis syndrome. While immunoglobulin E is not involved, the mechanism(s) that result in the food-induced gastrointestinal symptoms are unclear, although T cell activation has been considered. We report four cases of food protein-induced enterocolitis syndrome caused by different solid foods and without concomitant immunoglobulin E sensitization to milk and soya. Clinical and laboratory evidence of type I immunoglobulin E mediated food reactivity and food-induced T cell activation was absent in each case.

Case presentations

Case 1 concerned a 20-month-old South Asian boy who had experienced four episodes of severe vomiting with flaccidity since four months of age and two hours after consuming rice.

Case 2 involved a nine-month-old Caucasian boy who had suffered three episodes of severe vomiting with flaccidity since six months of age and three hours after consuming wheat.

The child in Case 3 was a 16-month-old Caucasian boy who had suffered three episodes of severe vomiting with flaccidity since nine months of age and two hours after consuming cod.

Case 4 involved a 15-month-old South Asian boy who had suffered three episodes of severe vomiting since eight months of age and two hours after consuming chicken.

Conclusion

In children with recurrent marked delayed vomiting after the ingestion of specific foods and in whom bronchospasm, skin rash and angioedema are absent, food protein-induced enterocolitis syndrome should be considered. Skin prick testing and specific immunoglobulin E antibodies are negative and the mechanism of the vomiting is unclear. We speculate whether food protein-induced oligoclonal T cell activation may be present. This has similarities to various animal models and improvement may involve deletion of these T cells.

Differentiating food allergies from food intolerances

Adverse reactions to foods are extremely common, and generally they are attributed to allergy. However, clinical manifestations of various degrees of severity related to ingestion of foods can arise as a result of a number of disorders, only some of which can be defined as allergic, implying an immune mechanism. Recent epidemiological data in North America showed that the prevalence of food allergy in children has increased. The most common food allergens in the United States include egg, milk, peanut, tree nuts, wheat, crustacean shellfish, and soy. This review examines the various forms of food intolerances (immunoglobulin E [IgE] and non-IgE mediated), including celiac disease and gluten sensitivity. Immune mediated reactions can be either IgE mediated or non-IgE mediated. Among the first group, Immediate GI hypersensitivity and oral allergy syndrome are the best described. Often, but not always, IgE-mediated food allergies are entities such as eosinophilic esophagitis and eosinophilic gastroenteropathy. Non IgE-mediated immune mediated food reactions include celiac disease and gluten sensitivity, two increasingly recognized disorders. Finally, non-immune mediated reactions encompass different categories such as disorders of digestion and absorption, inborn errors of metabolism, as well as pharmacological and toxic reactions.

Is cow's milk harmful to a child's health?

Discussions and debates have recently emerged on the potential positive and negative effects of cow's milk in the paediatric community, also under the pressure of public opinion. The negative effects of cow's-milk consumption seem to be limited to iron status up to 9 to 12 months; then no negative effects are observed, provided that cow's milk, up to a maximum daily intake of 500 mL, is adequately complemented with iron-enriched foods. Lactose intolerance can be easily managed and up to 250 mL/day of milk can be consumed. Allergy to cow's-milk proteins is usually transient. Atopic children may independently be at risk for poor growth, and the contribution of dairy nutrients to their diet should be considered. The connection of cow's milk to autistic spectrum disorders is lacking, and even a cause-effect relation with type 1 diabetes mellitus has not been established because many factors may concur. Although it is true that cow's milk stimulates insulin-like growth factor-1 and may affect linear growth, association with chronic degenerative, noncommunicable diseases has not been established. Finally, fat-reduced milk, if needed, should be considered after 24 to 36 months. Cow's milk represents a major source of high nutritional quality protein as well as of calcium. Moreover, it has growth-promoting effects independent of specific compounds. Its protein and fat composition, together with the micronutrient content, is suggestive of a functional food, whose positive effects are emphasised by regular consumption, particularly under conditions of diets poor in some limiting nutrients, although in industrialised countries cow's milk's optimal daily intake should be around 500 mL, adequately complemented with other relevant nutrients.

Food protein-induced enterocolitis syndrome: an update on natural history and review of management

OBJECTIVES

To review the clinical features, pathophysiology, and management of food protein-induced enterocolitis syndrome (FPIES) and to discuss new observations in epidemiology and natural history.

DATA SOURCES

PubMed searches were performed for articles published between 1978 and May 2011 using the keywords food-induced enterocolitis and FPIES.

STUDY SELECTION

Articles were selected based on their relevance to the topic of this review. The newest developments in FPIES were defined by articles published in the past 3 years.

RESULTS

FPIES is a non-IgE-mediated gastrointestinal food hypersensitivity thought to be cell-mediated, although the exact pathophysiologic mechanism requires further study. In a recent birth cohort, the incidence of cow's milk FPIES was 0.34% in the first year of life compared with 0.5% for IgE-mediated cow's milk allergy. FPIES typically presents before 6 months of age in formula-fed infants with repetitive emesis, diarrhea, dehydration, and lethargy 1 to 5 hours after ingesting the offending food. Four cases of FPIES in breastfed infants have recently been reported. The most common offending foods are cow's milk, soy, and rice. Diagnosis is based primarily on clinical history and, when unclear, physician-supervised oral food challenges. FPIES is usually outgrown by school age. Although management remains avoidance of the offending food, observations that natural history varies for different foods has redefined the timing of reintroduction.

CONCLUSION

Early recognition of FPIES and removal of the offending food are imperative to prevent misdiagnosis and mismanagement of symptoms that may mimic other causes. Close follow-up is required to determine when foods may be added back into the diet.

The crying baby: what approach?

PURPOSE OF REVIEW

Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management.

RECENT FINDINGS

New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended.

SUMMARY

The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.

Current understanding of the immune mechanisms of food protein-induced enterocolitis syndrome

Food protein-induced enterocolitis syndrome (FPIES) is an under-recognized and frequently misdiagnosed non-IgE-mediated food hypersensitivity disorder, characterized by severe vomiting and/or diarrhea. Despite the potential severity of acute reactions, FPIES can be considered self-limiting as avoidance of the incriminating allergen(s) leads to resolution of symptoms. Symptoms typically begin in the first month of life in association with failure to thrive and may progress to acidemia and shock. Although FPIES is well established as a distinct clinical entity, its pathophysiology has not yet been clearly defined and requires further characterization. Several immunologic alterations have been reported in FPIES, suggesting the involvement of antigen-specific T cells and their production of proinflammatory cytokines that regulate the permeability of the intestinal barrier. Humoral immune responses may also be involved in the pathomechanism of FPIES. The aim of this article is to delineate the immunological characteristics of this disorder based on the existing reports and to review the possible pathophysiologic basis of this disease.