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Feketea G, Popp A, Ionescu DM, Berghea EC. Case Report: Food Protein-Induced Protein Losing Enteropathy (FPIPLE) in Infancy. Front Nutr 2022; 9:810409. [PMID: 35174199 PMCID: PMC8842671 DOI: 10.3389/fnut.2022.810409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/07/2022] [Indexed: 12/15/2022] Open
Abstract
Food-protein induced protein-losing enteropathy (FPIPLE) is a mixed IgE and non-IgE food allergy in infants along with eosinophilic gastrointestinal (GI) diseases (EGID). It is characterized by poor weight gain, edema, due to hypoproteinemia/hypoalbuminemia by enteral loss of proteins, anemia, eosinophilia, raised fecal α1-antitrypsin (α1AT), and specific-IgE and allergy skin prick test (SPT) positive for offending foods. Here, we describe 4 cases with the same clinical pattern (edema due to hypoproteinemia/hypoalbuminemia from enteral loss of proteins, confirmed by high α1AT in the stools and no other pathological findings explaining the hypoproteinemia including normal kidney and liver function parameters), and propose the term “food-protein induced protein-losing enteropathy” (FPIPLE) to define this clinical entity. We also propose diagnostic criteria and an empirical algorithm of a practical approach to the diagnosis and management for children suspected to have FPIPLE. These infants can be managed successfully with dietary modification. In our 4 cases, initially, an empirical elimination diet was applied, comprising the foods that had benn introduced in the infant's diet during the last month and, an extensively hydrolyzed or elemental formula was given. In a second approach, after evaluation by a pediatric allergist, an allergy test-directed dietary elimination alimentation was implemented, for mother and/or infant. It has yet to be demonstrated whether patients with FPIPLE are a subset of patients with EGID, and whether early intervention modifies the natural course.
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Affiliation(s)
- Gavriela Feketea
- Ph.D. School, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Pediatrics, Pediatric Allergy Outpatient Clinic, Karamandaneio Children Hospital, Patras, Greece
| | - Alina Popp
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Mother and Child Health, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniela Marcela Ionescu
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Pediatrics, Marie Curie Clinical Emergency Hospital for Children, Bucharest, Romania
- *Correspondence: Daniela Marcela Ionescu
| | - Elena Camelia Berghea
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Pediatrics, Marie Curie Clinical Emergency Hospital for Children, Bucharest, Romania
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Gargano D, Appanna R, Santonicola A, De Bartolomeis F, Stellato C, Cianferoni A, Casolaro V, Iovino P. Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns. Nutrients 2021; 13:1638. [PMID: 34068047 PMCID: PMC8152468 DOI: 10.3390/nu13051638] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023] Open
Abstract
Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.
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Affiliation(s)
- Domenico Gargano
- Allergy and Clinical Immunology Unit, San Giuseppe Moscati Hospital, 83100 Avellino, Italy; (D.G.); (F.D.B.)
| | - Ramapraba Appanna
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Antonella Santonicola
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Fabio De Bartolomeis
- Allergy and Clinical Immunology Unit, San Giuseppe Moscati Hospital, 83100 Avellino, Italy; (D.G.); (F.D.B.)
| | - Cristiana Stellato
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Antonella Cianferoni
- Division of Allergy and Immunology, The Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Vincenzo Casolaro
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
| | - Paola Iovino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (R.A.); (A.S.); (C.S.); (V.C.)
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Kalmpourtzidou A, Xinias I, Agakidis C, Mavroudi A, Mouselimis D, Tsarouchas A, Agakidou E, Karagiozoglou-Lampoudi T. Diet Quality: A Neglected Parameter in Children With Food Allergies. A Cross-Sectional Study. Front Pediatr 2021; 9:658778. [PMID: 33968858 PMCID: PMC8102985 DOI: 10.3389/fped.2021.658778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/29/2021] [Indexed: 12/17/2022] Open
Abstract
Background-Objective: With recent evidence suggesting that growth is no longer considered a major issue in children with food allergies (FA) on elimination diet, priority has shifted to diet quality to establish healthy eating patterns and prevent non-communicable diseases. The Diet Quality Index - International (DQI-I) could be useful for assessing the overall diet quality of FA-children. This study aimed to evaluate the impact of elimination diet on DQI-I in children with FA and the accuracy of DQI-I in reflecting nutrient intake. Materials-methods: In a prospective, cross-sectional, cohort study of FA-children (2-14 years), nutritional intake was evaluated using a 7-day food frequency questionnaire, 24-h dietary recall, and the DQI-I. Results: Of the 76 children recruited, 44.7% had multiple allergies. Mean overall DQI-I score was 52 points, with only 28% of participants having good overall DQI-I (≥60 points). DQI-I moderation and balance were the most affected domains. Participants with multiple allergies had higher DQI-I moderation and balance and lower vitamin D and Ca intake. Compared to toddlers, schoolchildren had higher DQI-I variety and lower moderation and received higher vitamin B2, vitamin B12, Ca, P, and Zn. The number of allergies, age, and milk avoidance were independently associated with adjusted DQI-I moderation and balance, energy, and certain micronutrient intake. Higher percentages of participants with good DQI-I received adequate amounts of Mn and vitamins A, B6, C, and folate than those with poor DQI-I. Conclusions: In children with FA on elimination diet, the DQI-I accurately captured the deflection of diet quality related to the development of chronic, non-communicable diseases through its moderation and balance components. This is DQI-I's main purpose as a healthy diet indicator and as such it would be a useful tool responding to the needs of the contemporary shifting of priorities in FA-children's diet from quantity to quality. Nevertheless, it does not accurately reflect the intake of certain micronutrients potentially compromised by elimination diets. Therefore, regular nutritional assessment utilizing both the DQI-I and tools assessing individual nutrient intakes along with professional nutrition counseling should be integral parts of the individualized management of children with FA to ensure adequate nutrient intake and establish healthy dietary patterns.
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Affiliation(s)
- Aliki Kalmpourtzidou
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, Thermi, Greece
| | - Ioannis Xinias
- 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, Thessaloniki, Greece
| | - Charalampos Agakidis
- 1st Department of Pediatrics, Faculty of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, Thessaloniki, Greece
| | - Antigoni Mavroudi
- 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, Thessaloniki, Greece
| | - Dimitrios Mouselimis
- 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, Thessaloniki, Greece
| | - Anastasios Tsarouchas
- 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, Thessaloniki, Greece
| | - Eleni Agakidou
- 1st Department of Neonatology & Neonatal Intensive Care Unit (NICU), Faculty of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, Thessaloniki, Greece
| | - Thomai Karagiozoglou-Lampoudi
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, Thermi, Greece
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Jo SY, Lee CH, Jung WJ, Kim SW, Hwang YH. Common features of atopic dermatitis with hypoproteinemia. KOREAN JOURNAL OF PEDIATRICS 2018; 61:348-354. [PMID: 30304908 PMCID: PMC6258965 DOI: 10.3345/kjp.2018.06324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/06/2018] [Indexed: 01/19/2023]
Abstract
Purpose The purpose of this study was to identify the causes, symptoms, and complications of hypoproteinemia to prevent hypoproteinemia and provide appropriate treatment to children with atopic dermatitis. Methods Children diagnosed with atopic dermatitis with hypoproteinemia and/or hypoalbuminemia were retrospectively reviewed. The patients’ medical records, including family history, weight, symptoms, treatment, complications, and laboratory test results for allergies and skin cultures, were examined. Results Twenty-six patients (24 boys) were enrolled. Seven cases had growth retardation; 7, keratoconjunctivitis; 6, aural discharges; 5, eczema herpeticum; 4, gastrointestinal tract symptoms; and 2, developmental delays. In 21 cases, topical steroids were not used. According to the blood test results, the median values of each parameter were elevated: total IgE, 1,864 U/mL; egg white-specific IgE, 76.5 kUA/L; milk IgE, 20.5 kUA/L; peanut IgE, 30 kUA/L; eosinophil count, 5,810/μL; eosinophil cationic protein, 93.45 μg/L; and platelet count, 666.5×103/μL. Serum albumin and total protein levels decreased to 2.7 g/dL and 4.25 g/dL, respectively. Regarding electrolyte abnormality, 10 patients had hyponatremia, and 12, hyperkalemia. Systemic antibiotics were used to treat all cases, and an antiviral agent was used in 12 patients. Electrolyte correction was performed in 8 patients. Conclusion Hypoproteinemia accompanying atopic dermatitis is common in infants younger than 1 year and may occur because of topical steroid treatment continuously being declined or because of eczema herpeticum. It may be accompanied by growth retardation, keratoconjunctivitis, aural discharge, and eczema herpeticum and can be managed through skin care and topical steroid application without intravenous albumin infusion.
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Affiliation(s)
- So Yoon Jo
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Chan-Ho Lee
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Woo-Jin Jung
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Sung-Won Kim
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Yoon-Ha Hwang
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
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Nutritional management of cow's milk allergy in children: An update. Arch Pediatr 2018; 25:236-243. [PMID: 29576253 DOI: 10.1016/j.arcped.2018.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/29/2018] [Indexed: 12/23/2022]
Abstract
Cow's milk is one of the most common foods responsible for allergic reactions in children. Cow's milk allergy (CMA) involves immunoglobulin E (IgE)- and non-IgE-mediated reactions, the latter being both variable and nonspecific. Guidelines thus emphasize the need for physicians to recognize the specific syndromes of CMA and to respect strict diagnostic modalities. Whatever the clinical pattern of CMA, the mainstay of treatment is the elimination from the diet of cow's milk proteins. The challenge is that both the disease and the elimination diet may result in insufficient height and weight gain and bone mineralization. If, during CMA, the mother is not able or willing to breastfeed, the child must be fed a formula adapted to CMA dietary management, during infancy and later, if the disease persists. This type of formula must be adequate in terms of allergic efficacy and nutritional safety. In older children, when CMA persists, the use of cow's milk baked or heated at a sufficient temperature, frequently tolerated by children with CMA, may help alleviate the stringency of the elimination diet. Guidance on the implementation of the elimination diet by qualified healthcare professionals is always necessary. This guidance should also include advice to ensure adequate bone growth, especially relating to calcium intake. Specific attention should be given to children presenting with several risk factors for weak bone mineral density, i.e., multiple food allergies, vitamin D deficiency, poor sun exposure, steroid use, or severe eczema. When CMA is outgrown, a prolonged elimination diet may negatively impact the quality of the diet over the long term.
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Clinical Significance of Atopic Dermatitis with Hypoalbuminemia in Korean Children. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.7702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mori F, Serranti D, Barni S, Pucci N, Rossi ME, de Martino M, Novembre E. A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis. Nutr J 2015; 14:83. [PMID: 26293684 PMCID: PMC4545991 DOI: 10.1186/s12937-015-0071-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 08/04/2015] [Indexed: 11/22/2022] Open
Abstract
Although several cases of severe hypoalbuminemia resulting from rice milk have been described in the past, today the use of rice milk without nutritional counseling to treat eczema is still a continuing, poor practice. We describe a kwashiorkor case in an infant with severe eczema exclusively fed with rice milk. It is well documented that rice milk is not a sufficient protein source. Moreover, only a small portion of eczema is triggered by food allergy. In conclusion this case raises the importance of managing dietary changes facing food allergies with responsibility for specialized consensus among pediatricians, nutritionists, endocrinologists and allergists all of them specialist professionals.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Daniele Serranti
- Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Simona Barni
- Allergy Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Neri Pucci
- Allergy Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Maria Elisabetta Rossi
- Allergy Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Maurizio de Martino
- Infectious Diseases Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
| | - Elio Novembre
- Allergy Unit, Anna Meyer Children's University Hospital, Viale Pieraccini 24, 50139, Florence, Italy.
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Growth and nutritional concerns in children with food allergy. Curr Opin Allergy Clin Immunol 2014; 13:275-9. [PMID: 23510952 DOI: 10.1097/aci.0b013e328360949d] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe the potential effect that avoidance diets for food allergy may have on nutrition and growth in children. RECENT FINDINGS We report here the findings from the previous studies suggesting impairment of growth and nutritional deficiencies because of elimination diets for food allergy. Feeding difficulties have also been reported, particularly in children with eosinophilic esophagitis that may further impact the nutrient intake. SUMMARY Food allergies are becoming more prevalent and better recognized. Treatment options typically include strict dietary elimination of major food allergens such as milk, eggs, wheat, soy, peanut, tree nuts, fish and shellfish. Monitoring growth and guiding food allergic patients in choosing appropriate alternatives to supply necessary nutrients becomes crucial to avoid deficiencies and retardation in growth.
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Abstract
The age at which the majority of children outgrow cow's milk allergy now appears to be later than previously reported. Recent studies have attempted to elucidate factors that may help prevent cow's milk allergy, assess markers of persistence, and evaluate the usefulness of new diagnostic methods. Strict avoidance of cow's milk has been the mainstay of treatment. However, given the potential nutritional, social, and immunologic ramifications of cow's milk elimination from a child's diet, there has been a focus on reevaluating this therapeutic approach.
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Park JH, Shin Y, Park GH, Kim SW. The investigation of hypoproteinemia in pediatric atopic dermatitis. ALLERGY ASTHMA & RESPIRATORY DISEASE 2013. [DOI: 10.4168/aard.2013.1.4.344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jong Ha Park
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Yonghye Shin
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Geun Hwa Park
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
| | - Sung Won Kim
- Department of Pediatrics, Busan St. Mary's Hospital, Busan, Korea
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Park GH, Park JH, Hwang YH, Sung MS, Kim SW. The correlation between the severity of atopic dermatitis classified by SCORing atopic dermatitis index and the laboratory tests. ALLERGY ASTHMA & RESPIRATORY DISEASE 2013. [DOI: 10.4168/aard.2013.1.1.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Geun Hwa Park
- Department of Pediatrics, Busan St. Mary's Medical Center, Busan, Korea
| | - Jong Ha Park
- Department of Pediatrics, Busan St. Mary's Medical Center, Busan, Korea
| | - Yoon Ha Hwang
- Department of Pediatrics, Busan St. Mary's Medical Center, Busan, Korea
| | - Myong Sun Sung
- Department of Pediatrics, Busan St. Mary's Medical Center, Busan, Korea
| | - Sung Won Kim
- Department of Pediatrics, Busan St. Mary's Medical Center, Busan, Korea
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Diamanti A, Pedicelli S, D'Argenio P, Panetta F, Alterio A, Torre G. Iatrogenic Kwashiorkor in three infants on a diet of rice beverages. Pediatr Allergy Immunol 2011; 22:878-9. [PMID: 22122793 DOI: 10.1111/j.1399-3038.2011.01180.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fiocchi A, Brozek J, Schünemann H, Bahna SL, von Berg A, Beyer K, Bozzola M, Bradsher J, Compalati E, Ebisawa M, Guzman MA, Li H, Heine RG, Keith P, Lack G, Landi M, Martelli A, Rancé F, Sampson H, Stein A, Terracciano L, Vieths S. World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. World Allergy Organ J 2010; 3:57-161. [PMID: 23268426 PMCID: PMC3488907 DOI: 10.1097/wox.0b013e3181defeb9] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Hwang JB, Kang YN, Won KS. Protein losing enteropathy in severe atopic dermatitis in an exclusively breast-fed infant. Pediatr Dermatol 2009; 26:638-9. [PMID: 19840339 DOI: 10.1111/j.1525-1470.2009.01008.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We first report a case of protein losing enteropathy in severe atopic dermatitis in an exclusively breast-fed 5-month-old infant. Protein losing enteropathy was confirmed by fecal alpha1-antitrypsin clearance test and imaged successfully by 99mTc-human serum albumin scintigraphy. The present case highlights that protein losing enteropathy in severe infantile atopic dermatitis is being a topic of concern and also an issue even in exclusive breast feeding patients.
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Affiliation(s)
- Jin-Bok Hwang
- Department of Pediatrics, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea.
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