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Ribes-Koninckx C, Amil-Dias J, Espin B, Molina M, Segarra O, Diaz-Martin JJ. The use of amino acid formulas in pediatric patients with allergy to cow's milk proteins: Recommendations from a group of experts. Front Pediatr 2023; 11:1110380. [PMID: 37033186 PMCID: PMC10073469 DOI: 10.3389/fped.2023.1110380] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
One of the most common food allergies in children is cow's milk allergy (CMA). In breast-fed infants with CMA, the mother is encouraged to avoid dairy products. If this is not possible, or in formula fed infants, use of hypoallergenic replacement formulas such as extensively hydrolyzed formulas (EHF) is recommended. However, in ∼5% of patients EHFs are not tolerated and/or allergy symptoms can persist. When EHFs are ineffective and in severe forms of CMA, amino acid-based formulas (AAF) should be considered. Six pediatric gastroenterologists with extensive experience in food allergy management reviewed scientific publications and international clinical practice guidelines to provide practical recommendations on AAF. The guidelines reviewed had discrepancies and ambiguities around the specific indications for using formulas as a milk substitute. The panel recommends AAFs as the first therapeutic option in anaphylaxis due to CMA, in acute and chronic severe food protein-induced enterocolitis syndrome, in CMA associated with multiple food allergy, and in cases of eosinophilic esophagitis not responding to an extended exclusion diet or not eating solids. The main benefit of AAF is its absence of residual allergenicity, making it a safe treatment option in severe CMA patients who do not tolerate or respond to an EHF.
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Affiliation(s)
- Carmen Ribes-Koninckx
- Pediatric Gastroenterology, Hepatology and Nutrition La Fe University and Politechnic Hospital & La Fe Research Institute, Valencia, Spain
- Correspondence: Carmen Ribes-Koninckx
| | - Jorge Amil-Dias
- Emeritus, S. João University Hospital Center, Porto, Portugal
| | - Beatriz Espin
- Pediatric Gastroenterology and Nutrition Unit, Virgen del Rocio University Hospital, Seville, Spain
| | - Manuel Molina
- Department of Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | - Oscar Segarra
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan J. Diaz-Martin
- Pediatric Gastroenterology and Nutrition, Hospital Universitario Central de Asturias, Oviedo, Spain
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2
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Meyer R, Vandenplas Y, Lozinsky AC, Vieira MC, Canani RB, Dupont C, Uysal P, Cavkaytar O, Knibb R, Fleischer DM, Nowak-Wegrzyn A, Venter C. Diagnosis and management of food allergy-associated gastroesophageal reflux disease in young children-EAACI position paper. Pediatr Allergy Immunol 2022; 33:e13856. [PMID: 36282131 DOI: 10.1111/pai.13856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
Gastro-oesophageal reflux (GOR) and food allergy (FA) are common conditions, especially during the first 12 months of life. When GOR leads to troublesome symptoms, that affect the daily functioning of the infant and family, it is referred to as GOR disease (GORD). The role of food allergens as a cause of GORD remains controversial. This European Academy of Allergy and Clinical Immunology (EAACI) position paper aims to review the evidence for FA-associated GORD in young children and translate this into clinical practice that guides healthcare professionals through the diagnosis of suspected FA-associated GORD and medical and dietary management. The task force (TF) on non-IgE mediated allergy consists of EAACI experts in paediatric gastroenterology, allergy, dietetics and psychology from Europe, United Kingdom, United States, Turkey and Brazil. Six clinical questions were formulated, amended and approved by the TF to guide this publication. A systematic literature search using PubMed, Cochrane and EMBASE databases (until June 2021) using predefined inclusion criteria based on the 6 questions was used. The TF also gained access to the database from the European Society of Paediatric Gastroenterology and Hepatology working group, who published guidelines on GORD and ensured that all publications used within that position paper were included. For each of the 6 questions, practice points were formulated, followed by a modified Delphi method consisting of anonymous web-based voting that was repeated with modified practice points where required, until at least 80% consensus for each practice point was achieved. This TF position paper shares the process, the discussion and consensus on all practice points on FA-associated GORD.
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Affiliation(s)
- Rosan Meyer
- Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department Nutrition and Dietetics, Winchester University, Winchester, London, UK.,Department Paediatrics, Imperial College, London, UK
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Adriana Chebar Lozinsky
- Department of Allergy and Immune Disorders, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Mario C Vieira
- Department of Paediatrics-Pontifical Catholic University of Paraná and Center for Pediatric Gastroenterology-Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Roberto Berni Canani
- Department of Translational Medical Science and ImmunoNutritionLab at CEINGE-Advanced Biotechnologies Research Center, University of Naples "Federico II", Naples, Italy
| | - Christophe Dupont
- Department of Paediatric Gastroenterology, Necker University Children Hospital, Paris, France
| | - Pinar Uysal
- Department of Allergy and Clinical Immunology, Adnan Menderes University, Aydin, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Rebecca Knibb
- School of Psychology, Aston University, Birmingham, UK
| | - David M Fleischer
- University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, New York City, New York, USA.,Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Carina Venter
- University of Colorado Denver School of Medicine Children's Hospital Colorado, Aurora, Colorado, USA
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Salvatore S, Agosti M, Baldassarre ME, D’Auria E, Pensabene L, Nosetti L, Vandenplas Y. Cow's Milk Allergy or Gastroesophageal Reflux Disease-Can We Solve the Dilemma in Infants? Nutrients 2021; 13:297. [PMID: 33494153 PMCID: PMC7909757 DOI: 10.3390/nu13020297] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Cow's milk allergy (CMA) and gastro-esophageal reflux disease (GERD) may manifest with similar symptoms in infants making the diagnosis challenging. While immediate reaction to cow's milk protein indicate CMA, regurgitation, vomiting, crying, fussiness, poor appetite, sleep disturbances have been reported in both CMA and GERD and in other conditions such as functional gastrointestinal disorders, eosinophilic esophagitis, anatomic abnormalities, metabolic and neurological diseases. Gastrointestinal manifestations of CMA are often non-IgE mediated and clinical response to cow's milk free diet is not a proof of immune system involvement. Neither for non-IgE CMA nor for GERD there is a specific symptom or diagnostic test. Oral food challenge, esophageal pH impedance and endoscopy are recommended investigations for a correct clinical classification but they are not always feasible in all infants. As a consequence of the diagnostic difficulty, both over- and under- diagnosis of CMA or GERD may occur. Quite frequently acid inhibitors are empirically started. The aim of this review is to critically update the current knowledge of both conditions during infancy. A practical stepwise approach is proposed to help health care providers to manage infants presenting with persistent regurgitation, vomiting, crying or distress and to solve the clinical dilemma between GERD or CMA.
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Affiliation(s)
- Silvia Salvatore
- Department of Medicine and Surgery, Pediatric Unit, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy; (M.A.); (L.N.)
| | - Massimo Agosti
- Department of Medicine and Surgery, Pediatric Unit, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy; (M.A.); (L.N.)
| | - Maria Elisabetta Baldassarre
- Department of Biomedical Sciences and Human Oncology-Neonatology and NICU Section, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy;
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Luana Nosetti
- Department of Medicine and Surgery, Pediatric Unit, “F. Del Ponte” Hospital, University of Insubria, 21100 Varese, Italy; (M.A.); (L.N.)
| | - Yvan Vandenplas
- Kidz Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium;
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Presentation and Management of Food Allergy in Breastfed Infants and Risks of Maternal Elimination Diets. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:52-67. [DOI: 10.1016/j.jaip.2019.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
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Pensabene L, Salvatore S, D'Auria E, Parisi F, Concolino D, Borrelli O, Thapar N, Staiano A, Vandenplas Y, Saps M. Cow's Milk Protein Allergy in Infancy: A Risk Factor for Functional Gastrointestinal Disorders in Children? Nutrients 2018; 10:E1716. [PMID: 30423934 PMCID: PMC6265683 DOI: 10.3390/nu10111716] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/04/2018] [Accepted: 11/06/2018] [Indexed: 12/12/2022] Open
Abstract
The role and prevalence of cow's milk protein allergy (CMA) in functional gastrointestinal disorders remains unclear. The aim of this review is to update knowledge on the relationship between CMA and functional abdominal pain disorders (FAPDs) in children. Cochrane Database and Pubmed were searched from inception using general and specific terms for CMA and functional gastrointestinal disorders. CMA is reported as a predisposing or coexisting factor in a wide range of functional gastrointestinal disorders in infants and children. Pathogenesis of both conditions is complex and multiple mechanisms including dysmotility and hypersensitivity might contribute to the clinical manifestations. Data supporting the possible role of food allergies in the pathogenesis of FAPDs are limited. CMA may predispose to early life inflammation and visceral hypersensitivity, which in turn might manifest as FAPDs. The diagnosis of either CMA or FAPDs and distinction between them is challenging because of nonspecific and overlapping symptoms. Lack of accurate allergy tests in non-IgE (immunoglobulin E) mediated cases is also problematic. Oral food challenge, following an elimination diet, should be performed to diagnose a suspected non-IgE CMA allergy in children with FAPDs. In the management of FAPDs, an elimination diet should be considered for a limited period to verify if the symptoms improve or resolve.
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Affiliation(s)
- Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy.
| | - Silvia Salvatore
- Department of Medicine and Surgery, Section of Pediatrics, University of Insubria, 21100 Varese, Italy.
| | - Enza D'Auria
- Department of Pediatrics, Vittore Buzzi Children's Hospital-University of Milan, 20154 Milan, Italy.
| | - Francesca Parisi
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy.
| | - Daniela Concolino
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy.
| | - Osvaldo Borrelli
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK.
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, Department of Gastroenterology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK.
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", 80131 Naples, Italy.
| | - Yvan Vandenplas
- KidZ Health Castle, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium.
| | - Miguel Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Holtz Children's Hospital, University of Miami, Miller School of Medicine, Miami, FL 33136, USA.
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Caubet JC, Szajewska H, Shamir R, Nowak-Węgrzyn A. Non-IgE-mediated gastrointestinal food allergies in children. Pediatr Allergy Immunol 2017; 28:6-17. [PMID: 27637372 DOI: 10.1111/pai.12659] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 02/06/2023]
Abstract
Non-IgE-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) including food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE), and food protein-induced allergic proctocolitis (FPIAP) are relatively uncommon in infants and young children, but are likely under-diagnosed. Non-IgE-GI-FA have a favorable prognosis, with majority resolving by age 3-5 years. Diagnosis relies on the recognition of symptoms pattern in FPIAP and FPIES and biopsy in FPE. Further studies are needed for a better understanding of the pathomechanism, which will lead eventually to the development of diagnostic tests and treatments. Limited evidence supports the role of food allergens in subsets of constipation, gastroesophageal reflux disease, irritable bowel syndrome, and colic. The immunologic pathomechanism is not fully understood and empiric prolonged avoidance of food allergens should be limited to minimize nutrient deficiency and feeding disorders/food aversions in infants.
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Affiliation(s)
- Jean-Christoph Caubet
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Jaffe Food Allergy Institute, New York, NY, USA.,Department of Child and Adolescent, Medical School of the University of Geneva, University Hospitals of Geneva, Geneva, Switzerland
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Raanan Shamir
- Sackler Faculty of Medicine, Schneider Children's Medical Center of Israel, Institute for Gastroenterology, Nutrition and Liver Diseases, Tel-Aviv University, Tel-Aviv, Israel
| | - Anna Nowak-Węgrzyn
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Jaffe Food Allergy Institute, New York, NY, USA
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7
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Heine RG. Insights into the emerging epidemic of eosinophilic oesophagitis. Best Pract Res Clin Gastroenterol 2015; 29:731-737. [PMID: 26552772 DOI: 10.1016/j.bpg.2015.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 08/24/2015] [Accepted: 09/02/2015] [Indexed: 02/07/2023]
Abstract
Eosinophilic oesophagitis (EOE) is a relatively recently recognised condition characterised by an increase in oesophageal eosinophils. EOE occurs in children and adults with a strong male preponderance. There has been a sharp increase in EOE in North America, Europe and Australia. The reasons for this increase remain unclear but are likely to be influenced by genetic and environmental factors, as well as early-life exposures. Based on recent population-based data, the estimated EOE prevalence in the USA is 56.7 per 100,000 persons. The peak prevalence was observed in patients between 35 and 39 years of age. Prevalence figures in Asia and the Middle East generally appear to be lower than in Western countries, but population-based studies are not available. A causal association between coeliac disease and EOE appears unlikely. Data on the seasonal variation of EOE remain inconclusive. Further population-based studies are needed to define the epidemiology of EOE.
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Affiliation(s)
- Ralf G Heine
- Dept. of Gastroenterology & Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia; Dept. of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia.
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Nowak-Węgrzyn A, Katz Y, Mehr SS, Koletzko S. Non-IgE-mediated gastrointestinal food allergy. J Allergy Clin Immunol 2015; 135:1114-24. [PMID: 25956013 DOI: 10.1016/j.jaci.2015.03.025] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 03/25/2015] [Accepted: 03/25/2015] [Indexed: 01/07/2023]
Abstract
Non-IgE-mediated gastrointestinal food-induced allergic disorders (non-IgE-GI-FAs) account for an unknown proportion of food allergies and include food protein-induced enterocolitis syndrome (FPIES), food protein-induced allergic proctocolitis (FPIAP), and food protein-induced enteropathy (FPE). Non-IgE-GI-FAs are separate clinical entities but have many overlapping clinical and histologic features among themselves and with eosinophilic gastroenteropathies. Over the past decade, FPIES has emerged as the most actively studied non-IgE-GI-FA, potentially because of acute and distinct clinical features. FPIAP remains among the common causes of rectal bleeding in infants, while classic infantile FPE is rarely diagnosed. The overall most common allergens are cow's milk and soy; in patients with FPIES, rice and oat are also common. The most prominent clinical features of FPIES are repetitive emesis, pallor, and lethargy; chronic FPIES can lead to failure to thrive. FPIAP manifests with bloody stools in well-appearing young breast-fed or formula-fed infants. Features of FPE are nonbloody diarrhea, malabsorption, protein-losing enteropathy, hypoalbuminemia, and failure to thrive. Non-IgE-GI-FAs have a favorable prognosis; the majority resolve by 1 year in patients with FPIAP, 1 to 3 years in patients with FPE, and 1 to 5 years in patients with FPIES, with significant differences regarding specific foods. There is an urgent need to better define the natural history of FPIES and the pathophysiology of non-IgE-GI-FAs to develop biomarkers and novel therapies.
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Affiliation(s)
- Anna Nowak-Węgrzyn
- Jaffe Food Allergy Institute, Division of Pediatric Allergy, Mount Sinai School of Medicine, New York, NY.
| | - Yitzhak Katz
- Allergy and Immunology Institute, Assaf Harofeh Medical Center, Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sam Soheil Mehr
- Department of Allergy and Immunology, Children's Hospital at Westmead, Westmead, Australia
| | - Sibylle Koletzko
- Division of Gastroenterology and Hepatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
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Cervantes-Bustamante R, Pedrero-Olivares I, Toro-Monjaraz EM, Murillo-Márquez P, Ramírez-Mayans JA, Montijo-Barrios E, Zárate-Mondragón F, Cadena-León J, Cazares-Méndez M, López-Ugalde M. Histopathologic findings in children diagnosed with cow's milk protein allergy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 80:130-4. [PMID: 26024572 DOI: 10.1016/j.rgmx.2015.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 01/13/2015] [Accepted: 01/20/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cow's milk protein allergy is the most common cause of food allergy. The challenge test, either open or doubled-blind with a placebo control, is regarded as the criterion standard. Endoscopy and histologic findings are considered a method that can aid in the diagnosis of this entity. AIMS The aim of this study was to describe the histopathologic findings in children suspected of cow's milk protein allergy that were seen at our hospital. MATERIAL AND METHODS A descriptive, observational study was conducted on 116 children clinically suspected of presenting with cow's milk protein allergy that were seen at the Department of Gastroenterology and Nutrition of the Instituto Nacional de Pediatría. Upper endoscopy and rectosigmoidoscopy with biopsies were performed and the findings were described. RESULTS Of the 116 patients, 64 (55.17%) were girls and 52 (44.83%) were boys. The rectum was the site with the greatest presence of eosinophils per field in both groups, followed by the duodenum. In general, more than 15 eosinophils were found in 46% of the patients. CONCLUSIONS Between 40 and 45% of the cases had the histologic criterion of more than 15 to 20 eosinophils per field and the rectosigmoid colon was the most affected site. Therefore, panendoscopy and rectosigmoidoscopy with biopsy and eosinophil count are suggested.
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Affiliation(s)
- R Cervantes-Bustamante
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - I Pedrero-Olivares
- Servicio de Gastroenterología y Nutrición Pediátrica, Hospital de Alta Especialidad de Ixtapaluca, Secretaría de Salud,, Ixtapaluca, Estado de México, México
| | - E M Toro-Monjaraz
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México.
| | - P Murillo-Márquez
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - J A Ramírez-Mayans
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - E Montijo-Barrios
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - F Zárate-Mondragón
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - J Cadena-León
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - M Cazares-Méndez
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
| | - M López-Ugalde
- Departamento de Gastroenterología y Nutrición Pediátrica, Instituto Nacional de Pediatría, México, D.F., México
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Histopathologic findings in children diagnosed with cow's milk protein allergy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015. [DOI: 10.1016/j.rgmxen.2015.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Food allergy is defined as an adverse immune response towards food proteins or as a form of a food intolerance associated with a hypersensitive immune response. It should also be reproducible by a double-blind placebo-controlled food challenge. Many reported that food reactions are not allergic but are intolerances. Food allergy often presents to clinicians as a symptom complex. This review focuses on the clinical spectrum and manifestations of various forms of food allergies. According to clinical presentations and allergy testing, there are three types of food allergy: IgE mediated, mixed (IgE/Non-IgE), and non-IgE mediated (cellular, delayed type hypersensitivity). Recent advances in food allergy in early childhood have highlighted increasing recognition of a spectrum of delayed-onset non-IgE-mediated manifestation of food allergy. Common presentations of food allergy in infancy including atopic eczema, infantile colic, and gastroesophageal reflux. These clinical observations are frequently associated with food hypersensitivity and respond to dietary elimination. Non-IgE-mediated food allergy includes a wide range of diseases, from atopic dermatitis to food protein-induced enterocolitis and from eosinophilic esophagitis to celiac disease. The most common food allergies in children include milk, egg, soy, wheat, peanut, treenut, fish, and shellfish. Milk and egg allergies are usually outgrown, but peanut and treenut allergy tends to persist. The prevalence of food allergy in infancy is increasing and may affect up to 15-20 % of infants. The alarming rate of increase calls for a public health approach in the prevention and treatment of food allergy in children.
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Dupont C, Kalach N, Soulaines P, Bradatan E, Lachaux A, Payot F, de Blay F, Guénard-Bilbault L, Hatahet R, Mulier S. A thickened amino-acid formula in infants with cow's milk allergy failing to respond to protein hydrolysate formulas: a randomized double-blind trial. Paediatr Drugs 2014; 16:513-22. [PMID: 25446768 DOI: 10.1007/s40272-014-0097-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Amino-acid-based formulas (AAFs) are recommended for children with cow's milk protein allergy (CMPA) failing to respond to extensively hydrolyzed formulas (eHFs). OBJECTIVE This study aimed to assess the tolerance/hypoallergenicity and efficacy of a thickened AAF (TAAF) in these infants. METHODS This multicenter, double-blind, randomized controlled trial (NCT01940068) compared 3-month feeding with a pectin-based TAAF (Novalac(®), United Pharmaceuticals, Paris, France) and a commercially available "reference" AAF (RAAF; Neocate(®), Nutricia, Germany) in infants aged <18 months with CMPA and persistent allergy symptoms with eHF feeding. Reported here are the results of an interim analysis after 1 month of feeding. RESULTS Of the 86 infants randomized, CMPA with eHF intolerance was confirmed in 75 infants; all of them tolerated the allocated AAFs. The major allergic symptom disappeared within 1 month in 61.9 and 51.5 % and regurgitations disappeared in 66.7 and 42.3 % of infants who received TAAF and RAAF, respectively. Infants had significantly more normal stools (soft or formed consistency) with the TAAF (90.5 vs. 66.7 %; p = 0.011). From baseline, daily family life significantly improved with both AAFs: crying time decreased by 97.3 (p < 0.001) and 28.6 min (p = 0.014) and sleeping time increased by 64.6 (p = 0.009) and 29.0 min with TAAF and RAAF, respectively. At day 30, weight and body mass index z-score gains were 0.1 and 0.2 with TAAF and 0.2 and 0.0 with RAAF. CONCLUSION Both AAFs were well tolerated by infants with CMPA and eHF intolerance and ensured appropriate growth, with the TAAF providing additional comfort.
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Affiliation(s)
- Christophe Dupont
- Pediatric Gastroenterology, Hepatology and Nutrition Department, Necker Children's Hospital, 149, rue de Sèvres, 75015, Paris, France,
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Singendonk MMJ, Rommel N, Omari TI, Benninga MA, van Wijk MP. Upper gastrointestinal motility: prenatal development and problems in infancy. Nat Rev Gastroenterol Hepatol 2014; 11:545-55. [PMID: 24890279 DOI: 10.1038/nrgastro.2014.75] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Deglutition, or swallowing, refers to the process of propulsion of a food bolus from the mouth into the stomach and involves the highly coordinated interplay of swallowing and breathing. At 34 weeks gestational age most neonates are capable of successful oral feeding if born at this time; however, the maturation of respiration is still in progress at this stage. Infants can experience congenital and developmental pharyngeal and/or gastrointestinal motility disorders, which might manifest clinically as gastro-oesophageal reflux (GER) symptoms, feeding difficulties and/or refusal, choking episodes and airway changes secondary to micro or overt aspiration. These problems might lead to impaired nutritional intake and failure to thrive. These gastrointestinal motility disorders are mostly classified according to the phase of swallowing in which they occur, that is, the oral preparatory, oral, pharyngeal and oesophageal phases. GER is a common phenomenon in infancy and is referred to as GERD when it causes troublesome complications. GER is predominantly caused by transient relaxation of the lower oesophageal sphincter. In oesophageal atresia, oesophageal motility disorders develop in almost all patients after surgery; however, a congenital origin of disordered motility has also been proposed. This Review highlights the prenatal development of upper gastrointestinal motility and describes the most common motility disorders that occur in early infancy.
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Affiliation(s)
- Maartje M J Singendonk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Nathalie Rommel
- Department of Neurosciences, ExpORL, KU Leuven, O&N II Herenstraat 49, Box 721, 3000 Leuven, Belgium
| | - Taher I Omari
- Gastroenterology Unit, Women's and Children's Health Network, 72 King William Street, 5006 SA, Australia
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Michiel P van Wijk
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
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Borrelli O, Mancini V, Thapar N, Giorgio V, Elawad M, Hill S, Shah N, Lindley KJ. Cow's milk challenge increases weakly acidic reflux in children with cow's milk allergy and gastroesophageal reflux disease. J Pediatr 2012; 161:476-481.e1. [PMID: 22513270 DOI: 10.1016/j.jpeds.2012.03.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 02/06/2012] [Accepted: 03/02/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess and compare the pattern of reflux in a selected population of infants with cow's milk (CM) allergy (CMA) and suspected gastroesophageal reflux disease (GERD) while on dietary exclusion and following challenge with CM. STUDY DESIGN Seventeen children (median age: 14 months) with a proven diagnosis of CMA and suspected GERD underwent 48-hour multichannel intraluminal impedance-pH monitoring. For the first 24 hours, the infants were kept on amino acid-based formula, and for the subsequent 24 hours, they were challenged with CM. RESULTS The total reflux episodes and the number of weakly acidic episodes were higher during CM challenge compared with the amino acid-based formula period [total reflux episodes: 105 (58-127.5) vs 65 (39-87.5), P < .001; weakly acidic episodes: 53 (38.5-60.5) vs 19 (13-26.5), P < .001; median (25th-75th)]. No differences were found for either acid or weakly alkaline episodes (not significant). The number of weakly acidic episodes reaching the proximal, mid, and distal esophagus was higher during CM challenge (P < .001). No differences were found in either acid exposure time or number of long-lasting episodes (not significant). CONCLUSIONS In children with CMA and suspected GERD, CM exposure increases the number of weakly acidic reflux episodes. CM challenge during 48-hour multichannel intraluminal impedance-pH monitoring identifies a subgroup of patients with allergen-induced reflux, and in selected cases of children with CMA in whom GERD is suspected, its use could be considered as part of diagnostic work-up.
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Affiliation(s)
- Osvaldo Borrelli
- Neurogastroenterology and Motility Division, Department of Gastroenterology, Great Ormond Street Hospital for Sick Children and Institute of Child Health, London, United Kingdom.
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Goldani HA, Nunes DL, Ferreira CT. Managing gastroesophageal reflux disease in children: The role of endoscopy. World J Gastrointest Endosc 2012; 4:339-46. [PMID: 22912907 PMCID: PMC3423514 DOI: 10.4253/wjge.v4.i8.339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 06/28/2012] [Accepted: 08/08/2012] [Indexed: 02/05/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.
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Affiliation(s)
- Helena As Goldani
- Helena AS Goldani, Daltro LA Nunes, Cristina T Ferreira, Department of Pediatrics and Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, 90035-903 Porto Alegre-RS, Brazil
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De Greef E, Hauser B, Devreker T, Veereman-Wauters G, Vandenplas Y. Diagnosis and management of cow's milk protein allergy in infants. World J Pediatr 2012; 8:19-24. [PMID: 22282379 DOI: 10.1007/s12519-012-0332-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 09/08/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cow's milk protein allergy (CMPA) is frequently suspected in infants with a variety of symptoms. A thorough history and careful clinical examination are necessary to exclude other underlying diseases and to evaluate the severity of the suspected allergy. Care should be taken to diagnose CMPA adequately to avoid an unnecessary diet. DATA SOURCES We make recommendations based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. RESULTS Skin prick tests, patch tests and serum specific IgE are only indicative of CMPA. Breastfed infants have a decreased risk of developing CMPA; an elimination diet for the mother is indicated if CMPA is confirmed. If a food challenge is positive in formula fed infants, an extensively hydrolysed formula and cow's milk-free diet is recommended. If symptoms do not improve, an amino acid based formula should be considered. In severe CMPA with life-threatening symptoms, an amino-acid formula is recommended. CONCLUSIONS Elimination diet by a double-blind placebo controlled food challenge is the gold standard for diagnosis. Elimination of the offending allergen from the infants' diet is the main treatment principle.
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Hassall E. Over-prescription of acid-suppressing medications in infants: how it came about, why it's wrong, and what to do about it. J Pediatr 2012; 160:193-8. [PMID: 22018908 DOI: 10.1016/j.jpeds.2011.08.067] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/21/2011] [Accepted: 08/30/2011] [Indexed: 12/12/2022]
Affiliation(s)
- Eric Hassall
- Sutter Pacific Medical Foundation, San Francisco, CA 94118, USA.
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Farahmand F, Najafi M, Ataee P, Modarresi V, Shahraki T, Rezaei N. Cow's Milk Allergy among Children with Gastroesophageal Reflux Disease. Gut Liver 2011; 5:298-301. [PMID: 21927657 PMCID: PMC3166669 DOI: 10.5009/gnl.2011.5.3.298] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 01/20/2011] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Gastroesophageal reflux disease (GERD) and cow's milk allergy (CMA) are two common conditions that occur in infancy. This study was performed to investigate the frequency of CMA in a group of patients with GERD. Methods Eighty-one children with signs and symptoms of GERD were enrolled in this study. All subjects received omeprazole for 4 weeks after the initial evaluation. Empirical elimination of cow's milk from the diet was started for the patients who did not respond to the omeprazole treatment. Results Seventy-two cases presented with gastrointestinal signs and symptoms, whereas the remaining nine cases presented with respiratory complaints. After the initial treatment with omeprazole, two thirds of the cases (54 patients, 66.7%) responded well, and all of their symptoms were resolved. Cow's milk was eliminated from the diets of the remaining 27 patients. All signs and symptoms of GERD were resolved in this group after a 4 week elimination of cow's milk from the diet. Conclusions A diagnosis of CMA was considered in one third of the pediatric cases with signs and symptoms of GERD. This finding shows that CMA can mimic or aggravate all signs and symptoms of severe GERD during infancy.
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Affiliation(s)
- Fatemeh Farahmand
- Division of Pediatric Gastroenterology, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Eosinophilic esophagitis (EE) is a recently recognized form of pan-esophagitis, which is characterized by the presence of at least 15 eosinophils per high power field on esophageal histology. EE is closely associated with atopic disorders and occurs predominantly in male patients. Young children are more likely to be sensitized to food allergens whilst aeroallergen sensitization predominates in older children and adults--a pattern reminiscent of the "atopic march". EE presents with a diverse range of gastrointestinal symptoms, including regurgitation, vomiting, feeding difficulties or refusal in infancy, in addition to dysphagia and food bolus impaction in older children and adults. The diagnosis may also be ascertained incidentally in patients undergoing gastroscopy for other suspected gastrointestinal conditions, such as gastroesophageal reflux disease or celiac disease. Complications mainly relate to subepithelial remodeling and fibrosis which may result in dysmotility, dysphagia and esophageal strictures. The proportion of EE patients at risk of these complications is unknown due to a paucity of data on the natural history of EE. There are only few randomized controlled trials assessing the efficacy of treatment modalities for EE, which currently either involve food allergen elimination or use of swallowed aerosolized corticosteroids. This article aims to discuss the complex issues of the diagnosis and long-term management that confront clinicians who care for children with EE.
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Heine RG, Nethercote M, Rosenbaum J, Allen KJ. Emerging management concepts for eosinophilic esophagitis in children. J Gastroenterol Hepatol 2011; 26:1106-13. [PMID: 21545525 DOI: 10.1111/j.1440-1746.2011.06757.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition and Royal Children's Hospital, Melbourne, Australia
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Histological evaluation of esophageal mucosa in children with acid gastroesophageal reflux. Folia Histochem Cytobiol 2010; 47:297-306. [PMID: 19995717 DOI: 10.2478/v10042-009-0072-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIM histological evaluation of esophageal mucosa in children, with regard to the duration of primary acid gastroesophageal reflux (GER) and acid GER secondary to cow's milk allergy and/or other food allergy (CMA/FA) (prospective study). MATERIAL AND METHODS 264 children of both sexes suspected of GER were enrolled in the study. The age of examined children was 1.5-102 months, mean age 20.78+/-17.23 months. Pathological acid GER was confirmed with pH-monitoring in 138 children (52.3%). Taking into consideration complex differential diagnosis, including oral food challenge test with potentially noxious nutrient (open or blind study), children were assigned into study groups 1 and 2 (primary and secondary GER). Group 1: 76 patients (28.8%) aged 4-102 months (x=25.2+/-27.28 months) with primary GER. Group 2: 62 patients (23.5%) aged 4-74 months (x=21.53+/-17.79 months) with GER secondary to CMA/FA. Children with GERD underwent preliminary and control (after 1 year and 2 years of GERD diagnosis) endoscopic examination of the upper gastroinestinal tract. RESULTS Intensity of esophagitis was assessed initially in 25 children from group 1 (32.9%), in 29 children from group 2 (46.8%), and in 9 children from group 3 - reference group (28.1%). Histological evaluation revealed infiltration of inflammatory cells, mainly neutrophils and intraepithelial lymphocytes, and also eosinophils in 10 children (13.2%) with primary GER. Infiltration of eosinophils and lymphocytes was found in 5 children (8.1%) with secondary GER. In 8 children (25.0%) with food allergy there were only lymphocytes. Infiltration of neutrophils and lymphocytes and basal zone hyperplasia or infiltration of eosinophils and lymphocytes with elongation of lamina propria papillae was found in 10 children (13.1%) with primary GER and in 20 children (32.2%) with secondary GER. Differentiation of particular types of inflammatory cells in mucosal infiltration characterized histological picture in the following way: neutrophils in 21 children (27.6%) with primary GER, eosinophils in 22 children (35.5%) with secondary GER, lymphocytes in 15 children (19.7%) in children with primary GER and in 15 children (24.2%) with secondary GER. Histological examination of esophageal mucosa after 1 and 2 years of clinical observation and periodical conservative treatment in children with primary and secondary GER revealed significant alleviation of inflammatory abnormalities (with regard to the type of abnormalities and the number of particular types of inflammatory cells). CONCLUSIONS The value of histological findings obtained in own studies comprises the role of food allergy in pathogenesis of GER and is related to GER's contribution, both direct (primary reflux) and indirect (secondary reflux), to triggering off morphological results and clinical outcomes of esophagitis.
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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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Van Howe RS, Storms MR. Gastroesophageal reflux symptoms in infants in a rural population: longitudinal data over the first six months. BMC Pediatr 2010; 10:7. [PMID: 20149255 PMCID: PMC2831886 DOI: 10.1186/1471-2431-10-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 02/11/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing numbers of infants are receiving prescription medications for symptoms associated with gastroesophageal reflux. Our aim was to prospectively measure reported gastroesophageal reflux symptoms in healthy term infants for the first six months of life. METHODS In a prospective cohort study in the rural Upper Peninsula of Michigan, 128 consecutive maternal-infant pairs were followed for six months and administered the Infant Gastroesophageal Reflux Questionnaire Revised (I-GERQ-R) at the one-month, two-month, four-month, and six-month well-child visits. RESULTS The I-GERQ-R scores decreased with age. Average scores were 11.74 (SE = 5.97) at one-month, 9.97(4.92) at two-months, 8.44(4.39) at four-months, and 6.97(4.05) at six months. Symptoms associated with colic were greatest at one month of age. CONCLUSION Symptoms of gastroesophageal reflux as measured by the I-GERQ-R decrease with age in the first six months of life in otherwise healthy infants; however the I-GERQ-R may have difficulty differentiating gastroesophageal reflux disease from colic in those under 3 months of age.
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Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, Marquette, Michigan, USA.
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Sherman P, Hassall E, Fagundes-Neto U, Gold B, Kato S, Koletzko S, Orenstein S, Rudolph C, Vakil N, Vandenplas Y. Gastroösophageale Refluxkrankheit. Monatsschr Kinderheilkd 2010. [DOI: 10.1007/s00112-010-2165-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547. [PMID: 19745761 DOI: 10.1097/mpg.0b013e3181b7f563] [Citation(s) in RCA: 479] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. METHODS An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices. RESULTS More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population. CONCLUSIONS This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.
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Omari T, Lundborg P, Sandström M, Bondarov P, Fjellman M, Haslam R, Davidson G. Pharmacodynamics and systemic exposure of esomeprazole in preterm infants and term neonates with gastroesophageal reflux disease. J Pediatr 2009; 155:222-8. [PMID: 19394048 DOI: 10.1016/j.jpeds.2009.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 12/22/2008] [Accepted: 02/11/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize the pharmacodynamics and systemic exposure of esomeprazole in 26 preterm infants and term neonates with symptoms of gastroesophageal reflux and pathologic acid exposure. STUDY DESIGN Enrolled patients received oral esomeprazole 0.5 mg/kg once daily for 7 days. Twenty-four-hour esophagogastric pH-impedance monitoring was performed at baseline and on day 7. Pharmacokinetic analysis was performed on day 7. Symptoms occurring during the baseline and day 7 studies were recorded on a symptom chart. RESULTS There were no significant differences from baseline to day 7 of therapy in the frequency of bolus reflux, consistency of bolus reflux (liquid, mixed, or gas), extent of bolus reflux, or bolus clearance time. Acid bolus reflux episodes were reduced on therapy (median 30 vs 8, P < .001), as was the reflux index (mean % time esophageal pH < 4, 15.7% vs 7.1%, P < .001). The estimated geometric mean of area under the plasma concentration time curve during the dosing interval and observed maximum plasma concentration was 2.5 micromol x h/L and 0.74 micromol/L, respectively. The number of gastroesophageal reflux symptoms recorded over 24 hours was lower on therapy (median 22 vs 12, P < .05). CONCLUSIONS In preterm infants and term neonates esomeprazole produces no change in bolus reflux characteristics despite significant acid suppression.
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Affiliation(s)
- Taher Omari
- Gastroenterology Unit, Children, Youth and Women's Health Services, North Adelaide, SA, Australia.
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Sherman PM, Hassall E, Fagundes-Neto U, Gold BD, Kato S, Koletzko S, Orenstein S, Rudolph C, Vakil N, Vandenplas Y. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol 2009; 104:1278-95; quiz 1296. [PMID: 19352345 DOI: 10.1038/ajg.2009.129] [Citation(s) in RCA: 299] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population. METHODS Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system. RESULTS There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established. CONCLUSIONS The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.
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Affiliation(s)
- Philip M Sherman
- Gastroenterology-Pediatric, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Diagnostic clues for identification of nonorganic vs organic causes of food refusal and poor feeding. J Pediatr Gastroenterol Nutr 2009; 48:355-62. [PMID: 19274791 DOI: 10.1097/mpg.0b013e31818b1936] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Food refusal, poor feeding, and somatic symptoms such as vomiting, gagging, irritability and failure to thrive (FTT) are commonly found in both infantile feeding disorders (IFD) and common treatable medical conditions. Present diagnostic classifications for diagnosing IFD are complex and difficult to apply in daily practice, leading to underdiagnosis and delay in diagnosis of IFD. We attempted to identify parental and infantile behaviour patterns or symptoms that could help distinguish between organic or behavioural causes for these symptoms. METHODS We screened 226 children with poor feeding. After exclusion criteria, we divided the remaining 151 into 2 groups. The nonorganic group (n=83) included patients with onset of symptoms before age 2, persistent food aversion longer than 1 month, and a response to behavioural intervention. The second group consisted of children (n=68) presenting with similar characteristics, who responded to medical or nutritional therapy in which a final diagnosis of gastro-esophageal reflux disease, milk allergy, or idiopathic or nutritional FTT was made. RESULTS Poor intake, poor weight gain, or vomiting did not discriminate between organic and nonorganic causes. Factors indicating the presence of a behavioural cause included food refusal, food fixation, abnormal parental feeding practices, onset after a specific trigger, and presence of anticipatory gagging (P<0.0001 for all). CONCLUSIONS Integration of a few structured questions regarding infant behaviour, parental feeding practices, infant symptoms, and triggers for the onset of symptoms may help clinicians distinguish between organic and nonorganic causes for food refusal or low intake FTT.
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Abstract
OBJECTIVES It is not known whether the prevalence of childhood esophagitis has changed over time. In children, the intraepithelial eosinophil is considered the hallmark of esophageal inflammation. This study compares the prevalence of intraepithelial eosinophils in esophageal biopsies obtained from 1980-1988 and 2001-2002. PATIENTS AND METHODS This study reevaluated all of the esophageal biopsies obtained at a single center during 2 periods: 1980-1988 and 2001-2002. Histological appearances were characterized and eosinophils per high-power field were quantified. RESULTS In total, 1058 esophageal biopsies from 510 subjects were reviewed. Between 1980 and 1988, 247 biopsies from 188 subjects were evaluated. Of these, 62 subjects met the criteria for esophageal disease, and 106 had no specific pathological changes. Between 2001 and 2002, 811 biopsies from 322 subjects were evaluated. Of these, 132 subjects met the criteria for esophageal disease, and 182 had no specific pathological changes. A statistically significant increase in the prevalence of esophageal inflammatory disease was observed comparing the recent group with the remote group. Eosinophilic esophagitis is thought to be distinct from other types of esophagitis in pathogenesis, epidemiology, histology, and treatment. Some suggest the prevalence of eosinophilic esophagitis has increased in recent years. We sought evidence for an increase in histological changes consistent with eosinophilic esophagitis. No matter whether histology consistent with eosinophilic esophagitis was defined as 25, 20, 15, or 10 eosinophils per high-power field, no increase in prevalence was found. CONCLUSIONS This study demonstrated no evidence for a change in the density of eosinophilic infiltrates in esophageal biopsies during the 22-year study period. The study showed a statistically significant increase in the prevalence of esophageal inflammatory disease across the same period.
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Abstract
Gastro-oesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. Gastrointestinal food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. The diagnosis of food protein-induced gastrointestinal motility disorders is hampered by the absence of specific clinical features or useful laboratory markers. Gastrointestinal biopsies before commencing a hypoallergenic diet may provide the most important diagnostic clues. Early recognition is essential for the optimal management of these patients to prevent nutritional sequelae or aversive feeding behaviours. Treatment relies on hypoallergenic formulae, as well as maternal elimination diets in breast-fed infants. Further research is required to better define the pathological mechanisms and diagnostic markers of paediatric allergic gastrointestinal motility disorders. The following article will present three instructive cases followed by discussion of the clinical presentation, diagnosis, treatment and natural history of food allergic motility disorders in infancy and early childhood.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology & Clinical Nutrition Royal Children's Hospital, University of Melbourne, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.
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Ireland-Jenkin K, Wu X, Heine RG, Cameron DJS, Catto-Smith AG, Chow CW. Oesophagitis in children: reflux or allergy? Pathology 2008; 40:188-95. [PMID: 18203041 DOI: 10.1080/00313020701813727] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The prevalence of eosinophilic oesophagitis appears to be increasing in many countries, sometimes rapidly, although this may be partly due to increased disease recognition. Histological methods of assessment and diagnostic criteria vary considerably between major clinical centres. Oesophagitis with over 20 intraepithelial eosinophils per high power field is more likely to be due to allergy than gastro-oesophageal reflux induced acid-peptic mucosal injury. Typical eosinophilic oesophagitis shows involvement of the entire oesophagus, with basal cell proliferation occupying more than 50% of the thickness of the surface epithelium, and high numbers of intraepithelial eosinophils, sometimes concentrated on the surface or as contiguous clusters. Ulceration and prominent neutrophils are atypical and should suggest an alternative or co-existent disease. On endoscopy, the oesophagus may display the typical 'corrugated' mucosal appearance. Clinically, dysphagia or food impaction are the most characteristic symptoms. There is a strong association with other atopic diseases, especially asthma and eczema. To date no evidence has emerged of an increased malignancy risk. Patients with eosinophilic oesophagitis typically fail to respond to acid suppressive medications but respond well to either elemental/elimination diets or aerosolised swallowed corticosteroids. Long-term uncontrolled oesophageal eosinophilic inflammation may lead to progressive subepithelial fibrosis, potentially resulting in strictures or oesophageal narrowing.
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Affiliation(s)
- Kerryn Ireland-Jenkin
- Department of Anatomical Pathology, Royal Children's Hospital, Melbourne, Victoria, Australia
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Hassall E. Talk is cheap, often effective: symptoms in infants often respond to non-pharmacologic measures. J Pediatr 2008; 152:301-3. [PMID: 18280829 DOI: 10.1016/j.jpeds.2007.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/16/2007] [Indexed: 01/05/2023]
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Orenstein SR, McGowan JD. Efficacy of conservative therapy as taught in the primary care setting for symptoms suggesting infant gastroesophageal reflux. J Pediatr 2008; 152:310-4. [PMID: 18280832 DOI: 10.1016/j.jpeds.2007.09.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 08/07/2007] [Accepted: 09/05/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the efficacy of non-pharmacologic conservative therapy for infant gastroesophageal reflux disease (GERD). STUDY DESIGN Consenting parents of the first 50 screened infants who met inclusion/exclusion criteria including abnormal (>16/42) scores on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R; n = 40) were taught conservative therapy measures by each site's study nurse: feeding modifications, positioning, and tobacco smoke avoidance. We compared I-GERQ-R scores and symptom response details before and 2 weeks after institution of these measures with 2-tail Wilcoxon signed ranks test in the 37 infants (age range, 4-43 weeks; median age, 13 weeks) who completed the run-in. RESULTS The median initial and final scores were 23 (16-36) and 18 (7-34; P < .000001). The median score change was -5 (+6--16). Scores of 78% improved at all; 59% improved at least the threshold of 5 points; 24% became normal. Scores for individual symptoms related to regurgitation, crying, and arching improved significantly. CONCLUSIONS Two weeks of conservative therapy measures taught in primary care improved 59% beyond the 5-point threshold and normalized 24% of infants with symptom severity diagnostic for GERD, as substantiated with a responsiveness-validated instrument.
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Affiliation(s)
- Susan R Orenstein
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Hill DJ, Murch SH, Rafferty K, Wallis P, Green CJ. The efficacy of amino acid-based formulas in relieving the symptoms of cow's milk allergy: a systematic review. Clin Exp Allergy 2007; 37:808-22. [PMID: 17517094 DOI: 10.1111/j.1365-2222.2007.02724.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this systematic review was to evaluate the efficacy of amino acid-based formulas (AAF) in patients with cow's milk allergy (CMA). Studies were identified using electronic databases and bibliography searches. Subjects eligible for inclusion were patients of any age with CMA or symptoms suggestive of it. Comparisons of interest were AAF vs. extensively hydrolysed formula (eHF), AAF vs. soy-based formula (SF) and AAF vs. cow's milk or cow's milk-based formula. Outcomes of interest were gastrointestinal (GI), dermatological, respiratory and behavioural symptoms as well as growth. A total of 20 studies [three head-to-head randomized controlled trials (RCTs), three cross-over challenge RCTs, seven clinical trials (CTs) and seven case reports (CRs)] were included in the review. In infants with confirmed or suspected CMA, the use of an AAF was shown to be safe and efficacious. Findings from RCT comparisons of AAF with eHF showed that both formulas are equally efficacious at relieving the symptoms of CMA in confirmed or suspected cases. However, infants in specific subgroups (e.g. non-IgE mediated food-induced gastro-enterocolitis-proctitis syndromes with failure to thrive, severe atopic eczema, or with symptoms during exclusive breastfeeding) were more likely overall to benefit from AAF, as intolerance to eHF may occur. In such cases, symptoms persisting despite eHF feeding usually remit on AAF, and catch-up growth may be seen. Meta-analysis of the findings was not possible due to lack of homogenous reporting of outcomes in the original trials. This systematic review shows clinical benefit from use of AAF in both symptoms and growth in infants and children with CMA who fail to tolerate eHF. Further studies are required to determine the relative medical or economic value of initial treatment with AAF in infants at high risk of eHF intolerance.
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Affiliation(s)
- D J Hill
- Department of Allergy, Royal Children's Hospital, Melbourne, Australia
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Sabri MT, Hussain SZ, Shalaby TM, Orenstein SR. Morphometric histology for infant gastroesophageal reflux disease: evaluation of reliability in 497 esophageal biopsies. J Pediatr Gastroenterol Nutr 2007; 44:27-34. [PMID: 17204949 DOI: 10.1097/01.mpg.0000243424.01593.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We sought to determine the reliability of morphometric measurements on infant esophageal biopsies using a light microscope with eyepiece micrometer. METHODS We measured epithelial thickness, basal layer thickness (B), papillary height (P) and epithelial lymphocyte and eosinophil numbers on approximately 500 existing esophageal suction biopsies from infants previously evaluated for reflux esophagitis. We tested these measurements for interobserver, test-retest and internal consistency reliability. RESULTS Infants ages 0.25 to 23.75 (median, 6.25) months provided 497 biopsies. Both investigators scoring the biopsies independently judged 93% of them scorable. Of the biopsies scored by both, the 2 readings were within 0.15 of each other for P in 97% and for B in 81%. In addition to these correlative measures of consistency, categoric measures demonstrated that 373 (89%) of the 420 scorable biopsies with visible papillae produced agreement as to P being abnormal (317, 85%) or normal (56, 15%). Similarly, 360 (78%) of the 463 scorable biopsies produced agreement as to B being abnormal (339, 94%) or normal (21, 6%). P values were 0.17 to 0.94 (median, 0.67), and B values were 0.13 to 0.91 (median, 0.34). Lymphocytes numbered 0 to 40 (median 5) per high-power field. Only 12% had any eosinophils; none of those with completely normal morphometrics had any eosinophils; and only 2% had >5 eosinophils per high-power field. CONCLUSIONS Simple quantitative esophageal histological morphometric parameters are reliably measurable on suction biopsies from infants using a light microscope fitted with an ocular micrometer, even by nonpathologists.
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Affiliation(s)
- Mahmoud T Sabri
- Pediatric Gastroenterology, Geisinger Medical Center, Danville, PA, USA
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Osborn DA, Sinn J. Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [PMID: 17054180 DOI: 10.1002/14651858.cd003664.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Allergies and food reactions are common and may be associated with foods including adapted cow's milk formula. Formulas containing hydrolysed proteins have been used to treat infants with allergy or food intolerance. However, it is unclear whether hydrolysed formula can be advocated for prevention of allergy and food intolerance in infants without evidence of allergy or food intolerance. OBJECTIVES To determine the effect of feeding hydrolysed formulas on allergy and food intolerance in infants and children compared to adapted cow's milk or human breast milk. If hydrolysed formulas are effective, to determine what type of hydrolysed formula is most effective including extensively and partially hydrolysed formulas. To determine which infants benefit, including infants at low or high risk of allergy and infants receiving early, short term or prolonged formula feeding. SEARCH STRATEGY The standard search strategy of the Cochrane Neonatal Review Group was used. The review was updated with searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2006), MEDLINE (1966-March 2006), EMBASE (1980-March 2006) and CINAHL (1982-March 2006) and previous reviews including cross references. SELECTION CRITERIA Randomised and quasi-randomised trials that compare the use of a hydrolysed infant formula to human milk or cow's milk formula. Trials with >80% follow up of participants were eligible for inclusion. DATA COLLECTION AND ANALYSIS Eligibility of studies for inclusion, methodological quality and data extraction were assessed independently by each review author. Primary outcomes included clinical allergy, specific allergies and food intolerance. Meta-analysis was conducted using a fixed effects model. MAIN RESULTS Two trials compared early, short term hydrolysed formula to human milk feeding. No significant difference in infant allergy or childhood cow's milk allergy (CMA) were reported. No eligible trial compared prolonged hydrolysed formula to human milk feeding. Two trials compared early, short term hydrolysed formula to cow's milk formula feeding. No significant benefits were reported. One large quasi-random study reported a reduction in infant CMA of borderline significance in low risk infants (RR 0.62, 95% CI 0.38, 1.00). Ten eligible studies compared prolonged feeding with hydrolysed formula versus cow's milk formula in high risk infants. Meta-analysis found a significant reduction in infant allergy (seven studies, 2514 infants; typical RR 0.79, 95% CI 0.66, 0.94), but not in the incidence of childhood allergy (two studies, 950 infants; typical RR 0.85, 95% CI 0.69, 1.05). There was no significant difference in infant eczema (eight studies, 2558 infants, typical RR 0.84, 95% CI 0.68, 1.04), childhood eczema incidence (two studies, 950 infants, typical RR 0.83, 95% CI 0.63, 1.10), childhood eczema prevalence (one study, 872 infants; RR 0.66, 95% CI 0.43, 1.02), or infant or childhood asthma, rhinitis and food allergy. One study reported a significant reduction in infants with CMA with confirmed atopy (RR 0.36, 95% CI 0.15, 0.89). Subgroup analysis of trials blinded to formula found no significant difference in infant allergy (four studies, 2156 infants; typical RR 0.87, 95% CI 0.69, 1.08) or childhood allergy incidence (one study, 872 infants; RR 0.91, 95% CI 0.73, 1.14). No eligible trial examined the effect of prolonged hydrolysed formula feeding on allergy beyond early childhood. There is evidence that preterm or low birthweight infants fed a hydrolysed preterm formula have significantly reduced weight gain, but not in other growth parameters (head circumference or length). Studies in term infants report no adverse effects on growth. Subgroup analysis of trials of partially hydrolysed versus cow's milk formula found a significant reduction in infant allergy (six studies, 1391 infants; typical RR 0.79, 95% CI 0.65, 0.97) but not childhood allergy, or infant or childhood asthma, eczema or rhinitis. Methodological concerns were the same as for the overall analysis. Analysis of trials of extensively hydrolysed formula versus cow's milk formula found no significant differences in allergy or food intolerance. Infants fed extensively hydrolysed formula compared with partially hydrolysed formula had a significant reduction in food allergy (two studies, 341 infants; typical RR 0.43, 95% CI 0.19, 0.99), but there was no significant difference in all allergy or any other specific allergy incidence. Comparing extensively hydrolysed casein containing formula with cow's milk formula, one study (431 infants) reported a significant reduction in childhood allergy incidence (RR 0.72, 95% CI 0.53, 0.97). Meta-analysis found a significant reduction in infant eczema (three studies, 1237 infants; typical RR 0.71, 95% CI 0.51, 0.97). One study reported a significant reduction in childhood eczema incidence (RR 0.66, 95% CI 0.44, 0.98) and prevalence (RR 0.50, 95% CI 0.27, 0.92). AUTHORS' CONCLUSIONS There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant CMA. In view of methodological concerns and inconsistency of findings, further large, well designed trials comparing formulas containing partially hydrolysed whey, or extensively hydrolysed casein to cow's milk formulas are needed.
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Affiliation(s)
- D A Osborn
- Westmead Hospital, Neonatal Unit, Hawkesbury Road, Westmead, New South Wales, Australia
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Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol 2006; 6:220-5. [PMID: 16670518 DOI: 10.1097/01.all.0000225164.06016.5d] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW This review assesses the role of food allergy in the pathophysiology of gastroesophageal reflux disease, colic and constipation in infancy. RECENT FINDINGS Frequent regurgitation, persistent crying and constipation are common clinical problems in infancy. A subgroup of infants with these conditions may respond to hypoallergenic diets, but only few randomized clinical trials have been conducted. Skin prick testing and food-specific antibody levels are usually not elevated in these infants, whereas atopy patch testing may diagnostic. The mechanisms by which cow's milk and other food allergens induce gastrointestinal motility disorders are not understood. Apart from cell-mediated reactions, non-immunological effects of food constituents on gastrointestinal motility and gut microbiota may be involved in the pathogenesis. In the absence of reliable diagnostic tests, dietary elimination and re-challenge are usually required to confirm food allergy. A trial of amino acid-based formula or an oligoantigenic maternal elimination diet may be indicated in infants who have failed conventional medical treatment. SUMMARY Food allergy may contribute to gastroesophageal reflux disease, colic or constipation in infancy. Infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet. Further research is needed to define the mechanisms and clinical markers of gastrointestinal food allergy in infancy.
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Affiliation(s)
- Ralf G Heine
- Department of Allergy, Royal Children's Hospital, Parkville, Victoria, Australia.
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Heine RG, Jordan B, Lubitz L, Meehan M, Catto-Smith AG. Clinical predictors of pathological gastro-oesophageal reflux in infants with persistent distress. J Paediatr Child Health 2006; 42:134-9. [PMID: 16509914 DOI: 10.1111/j.1440-1754.2006.00812.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Gastro-oesophageal reflux (GOR) is common in infants with persistent crying. Empirical treatment with antireflux medications is common practice, although on clinical grounds it may be difficult to determine whether GOR is abnormal. AIMS To examine the diagnostic accuracy of clinical predictors of pathological GOR in infants with persistent crying. METHODS One hundred and fifty-one infants (82 male; median age 2.5 months, range 0.5-8.2 months) with persistent crying were prospectively studied. Crying and fussing were charted for 24 h, and parents completed a validated questionnaire on reflux symptoms. All infants underwent oesophageal 24-h pH monitoring. RESULTS Twenty-seven (17.9%) infants had pathological GOR with a fractional reflux time (FRT) >10%. There was no significant association between total crying duration per 24 and FRT (P = 0.84) or the number of reflux episodes (P = 0.68). Pathological GOR was more common in infants under 3 months, compared to older infants (P = 0.04). Feeding difficulties were significantly associated with pathological GOR (P = 0.02). Backarching was not increased in infants with GOR (P = 0.30). Pathological GOR was significantly associated with the frequency of regurgitation (P = 0.04), but not with vomitus volume (P = 0.62). Regurgitation more than 5 times daily was the most specific reflux symptom (specificity 70.9%), but was a poor predictor of pathological GOR (positive predictive value 22.2%). In the absence of frequent regurgitation or feeding difficulties, pathological GOR was unlikely (negative predictive value 87-90%). CONCLUSIONS Investigation and treatment of GOR in infants with persistent crying should be primarily directed at infants presenting with frequent regurgitation or feeding difficulties.
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Affiliation(s)
- Ralf G Heine
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Australia.
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Jordan B, Heine RG, Meehan M, Catto-Smith AG, Lubitz L. Effect of antireflux medication, placebo and infant mental health intervention on persistent crying: a randomized clinical trial. J Paediatr Child Health 2006; 42:49-58. [PMID: 16487390 DOI: 10.1111/j.1440-1754.2006.00786.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of medical antireflux treatment, and of an infant mental health consultation (IMHC), on persistent crying in infants and maternal distress. METHODS Infants under 9 months of age with persistent crying, and their mothers, were enrolled in a randomized placebo-controlled trial. At enrollment, a questionnaire on demographic and clinical details was completed by mothers, and maternal distress was measured (Experience of Motherhood Questionnaire; EMQ). Oesophageal 24-h pH monitoring was performed in all infants on day 2. At week 4, the cry chart and EMQ were repeated in conjunction with a final interview. RESULTS One hundred and three infants (56 under 3 months of age; 55 male) who were randomized to active medication (ranitidine plus cisapride; n = 34), placebo (n = 29) or IMHC (n = 40) completed the trial. There was a significant reduction in crying duration from baseline to week 4 (253 +/- 96.5 min vs 159 +/- 92.3 min per 24 h; P < 0.001), without differences between treatment groups (AVOVA: F = 0.75; P = 0.48). There was a modest improvement in EMQ scores from 44.9 +/- 8.6 at day 1 to 42.8 +/- 9.4 at week 4; P = 0.006. The improvement in maternal stress was similar in all treatment groups (Kruskal-Wallis chi2 = 0.354; P = 0.84), but subsequent admission to a mother-infant unit was significantly less frequent in the IMHC group (P < 0.05). CONCLUSION Antireflux medications and IMHC were not superior to placebo in treating infants with persistent crying. Although the reduction in maternal distress was similar in all treatment groups, the individualized IMHC reduced the need for subsequent admission to a mother-infant unit.
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Affiliation(s)
- Brigid Jordan
- Mental Health Service, Royal Children's Hospital, Melbourne, Victoria, Australia.
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Bischoff S, Crowe SE. Gastrointestinal food allergy: new insights into pathophysiology and clinical perspectives. Gastroenterology 2005; 128:1089-113. [PMID: 15825090 DOI: 10.1053/j.gastro.2004.08.015] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Adverse reactions to food that result in gastrointestinal symptoms are common in the general population; while only a minority of such individuals will have symptoms due to immunologic reactions to foods, gastrointestinal food allergies do exist in both children and adults. These immune reactions are mediated by immunoglobulin E-dependent and -independent mechanisms involving mast cells, eosinophils, and other immune cells, but the complexity of the underlying mechanisms of pathogenesis have yet to be fully defined. Knowledge of the spectrum of adverse reactions to foods that affect the digestive system, including gastrointestinal food allergy, is essential to correctly diagnose and manage the subset of patients with immunologically mediated adverse reactions to foods. Potentially fatal reactions to food necessitate careful instruction and monitoring on the part of health care workers involved in the care of individuals at risk of anaphylaxis. New methods of diagnosis and novel strategies for treatment, including immunologic modulation and the development of hypoallergenic foods, are exciting developments in the field of food allergy.
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Affiliation(s)
- Stephan Bischoff
- Department of Gastroenterology, University Medical School of Hannover, Germany
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Vandenplas Y, Badriul H, Verghote M, Hauser B, Kaufman L. Glass and antimony electrodes for oesophageal pH monitoring in distressed infants: how different are they? Eur J Gastroenterol Hepatol 2004; 16:1325-30. [PMID: 15618840 DOI: 10.1097/00042737-200412000-00015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Although antimony electrodes are by far the most popular for performing oesophageal pH monitoring, there are few data comparing the accuracy of glass and antimony electrodes. Therefore, we tested the accuracy of both electrodes in the prediction of oesophagitis. METHOD pH monitoring using a glass electrode and an antimony electrode was performed in 60 distressed infants, aged between 1 and 6 months. An upper endoscopy with oesophageal biopsies was also performed in all infants. RESULTS A reflux index (percentage of the total time with pH < 4.0) greater than 5% was considered to be abnormal and was found in 40/60 patients. Histological oesophagitis was present in 26/60 infants. The reflux index was > 5% with the glass electrode in 18/26 children with histological oesophagitis and with the antimony electrode in 10/26 children with histological oesophagitis. Histology of the oesophagus was normal in 22/40 children with abnormal pH monitoring. With the glass electrode, the mean reflux index in the group with oesophagitis was significantly higher than in the group with normal histology, although there was an important overlap. With the antimony electrode, the mean reflux indices in the groups with and without oesophagitis were not different. Regarding normal/abnormal, there was discordance in 35% of the pH studies. No reflux index could be related to a clinically useful sensitivity and specificity to predict oesophagitis. CONCLUSION The reflux index does not accurately predict oesophagitis. Oesophageal pH monitoring and endoscopy provide complementary information.
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Affiliation(s)
- Yvan Vandenplas
- Department of Paediatrics, Academic Children's Hospital, Free University of Brussels, Brussels, Belgium.
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Cheung KM, Oliver MR, Cameron DJS, Catto-Smith AG, Chow CW. Esophageal eosinophilia in children with dysphagia. J Pediatr Gastroenterol Nutr 2003; 37:498-503. [PMID: 14508223 DOI: 10.1097/00005176-200310000-00018] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Children occasionally have dysphagia in the absence of an apparent primary cause. Esophageal eosinophilia is sometimes seen in these patients at the time of upper endoscopy but its significance is not clear. Although eosinophilia is regarded by some as a histologic hallmark of childhood reflux esophagitis, it may in fact signal a primary eosinophilic esophagitis in children with dysphagia. Our aim was to evaluate esophagitis, acid reflux determined by pH probe, and esophageal eosinophilia in children with the primary complaint of dysphagia. METHODS A retrospective study was performed in 42 children, admitted for investigation of dysphagia, in whom no primary cause could be found. Twenty-one children (mean age +/- SD, 10.1 +/- 4.0 years) had esophageal eosinophilia and 21 children (8.3 +/- 4.7 years) did not. Clinical, endoscopic, manometric and esophageal pH parameters in these two groups were compared. RESULTS Patients with esophageal eosinophilia were more often male (p<0.01) with a history of allergy (p<0.001) and food bolus obstruction (p<0.05) requiring endoscopic removal. Their esophageal mucosa appeared wrinkled and thickened at endoscopy with basal cell proliferation, and large numbers of eosinophils in esophageal mucosal biopsies. Continuous esophageal pH records and motility studies, when obtained, were similar in both groups and were within normal values. CONCLUSION Children with dysphagia who have esophageal eosinophilia are unlikely to have pathologic gastroesophageal reflux.
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Affiliation(s)
- Ka Ming Cheung
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne
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Moore DJ, Tao BSK, Lines DR, Hirte C, Heddle ML, Davidson GP. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. J Pediatr 2003; 143:219-23. [PMID: 12970637 DOI: 10.1067/s0022-3476(03)00207-5] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To assess the efficacy of omeprazole in treating irritable infants with gastroesophageal reflux and/or esophagitis. STUDY DESIGN Irritable infants (n=30) 3 to 12 months of age met the entry criteria of esophageal acid exposure >5% (n=22) and/or abnormal esophageal histology (n=15). They completed a 4-week, randomized, double-blind, placebo-controlled crossover trial of omeprazole. Cry/fuss diary (minutes/24 hours) and a visual analogue scale of infant irritability as judged by parental impression were obtained at baseline and the end of each 2-week treatment period. RESULTS The reflux index fell significantly during omeprazole treatment compared with placebo (-8.9%+/-5.6%, -1.9%+/-2.0%, P<.001). Cry/fuss time decreased from baseline (267+/-119), regardless of treatment sequence (period 1, 203+/-99, P<.04; period 2, 188+/-121, P<.008). Visual analogue score decreased from baseline to period 2 (6.8+/-1.6, 4.8+/-2.9, P=.008). There was no significant difference for both outcome measures while taking either omeprazole or placebo. CONCLUSIONS Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability. Irritability improved with time, regardless of treatment.
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Affiliation(s)
- David John Moore
- Centre for Paediatric and Adolesent Gastroenterology, Women's and Children's Hospital, North Adelaide, SA 5006, Australia.
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Aboudiab T, Jarosson L, Chouraki JP, Dalleac A, Kohler C, Béné MC, Kolopp-Sarda MN. [Cow's milk protein intolerance revealed by anorexia]. Arch Pediatr 2003; 10:649-50. [PMID: 12907077 DOI: 10.1016/s0929-693x(03)00289-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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De Boissieu D, Waguet JC, Dupont C. The atopy patch tests for detection of cow's milk allergy with digestive symptoms. J Pediatr 2003; 142:203-5. [PMID: 12584547 DOI: 10.1067/mpd.2003.92] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Infants (n = 35) with digestive symptom were investigated for diagnosis of cow's milk allergy (CMA). Milk atopy patch tests (APTs) were positive in 19 of 24 CMA versus 1 of 11 in non-CMA patients (P <.001). This sensitivity (79%) and specificity (91%) suggest that the APT could improve the detection of conditions related to CMA.
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Abstract
Gastroesophageal reflux (GER) and cow milk allergy (CMA) occur frequently in infants younger than 1 year. In recent years, the relation between these 2 entities has been investigated and some important conclusions have been reached: in up to half of the cases of GER in infants younger than 1 year, there may be an association with CMA. In a high proportion of cases, GER is not only CMA associated but also CMA induced. The frequency of this association should induce pediatricians to screen for possible concomitant CMA in all infants who have GER and are younger than 1 year. With the exception of some patients with mild typical CMA manifestations (diarrhea, dermatitis, or rhinitis), the symptoms of GER associated with CMA are the same as those observed in primary GER. Immunologic tests and esophageal pH monitoring (with a typical pH pattern characterized by a progressive, slow decrease in esophageal pH between feedings) may be helpful if an association between GER and CMA is suspected, although the clinical response to an elimination diet and challenge is the only clue to the diagnosis. This article reviews the main features of GER and CMA, focusing on the aspects in common and the discrepancies between both conditions.
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Affiliation(s)
- Silvia Salvatore
- Pediatrics, Clinica Pediatrica di Varese, Università dell'Insubria, Brussels, Belgium
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Miele E, Staiano A, Tozzi A, Auricchio R, Paparo F, Troncone R. Clinical response to amino acid-based formula in neurologically impaired children with refractory esophagitis. J Pediatr Gastroenterol Nutr 2002; 35:314-9. [PMID: 12352519 DOI: 10.1097/00005176-200209000-00014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Chronic gastrointestinal symptoms and histologic changes of the esophagus unresponsive to standard treatments for gastroesophageal reflux disease (GERD) may be improved by the use of elemental formulas. The aim of our study was to evaluate the efficacy of a dietary trial in neurologically impaired children unresponsive to medical and surgical therapy for GERD. METHODS Nine children (three boys and six girls; median age, 44 months; range, 13-180 months) affected by cerebral palsy associated with severe mental retardation and with long-standing history of GERD were fed the elemental formula, Neocate, for a minimum of 4 weeks. Before and after the dietary trial, each child underwent endoscopy with esophageal biopsy and a cellobiose/mannitol sugar permeability test. The diagnosis of GERD was based on the microscopic changes of the esophagus. RESULTS Before the dietary trial, according to conventional histologic criteria, esophagitis was considered moderate in seven children and mild in two. Five of nine patients also had abnormal sugar permeability test results. During and after the dietary trial, seven of nine patients experienced resolution of their long-term symptom complaints. Furthermore, after the dietary trial, both endoscopic ( < 0.01) and histologic ( < 0.05) findings significantly improved. At 6-month follow-up, progressive reintroduction of individual dietary proteins, except for cow's milk protein, did not cause reappearance of the symptoms. CONCLUSIONS In neurologically impaired children unresponsive to conventional antireflux treatments, a course of a highly restricted diet with an amino acid-based formula may bring an immediate and sustained, endoscopically and histologically proven improvement in long-standing gastrointestinal symptoms and esophagitis.
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Affiliation(s)
- Erasmo Miele
- Department of Pediatrics and European Laboratory for the Invstigation of Food-Induced Diseases, University Federico II, Naples, Italy
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Abstract
Cow's milk allergy affects approximately 2% of infants under 2 years of age. This review summarizes the recent advances in understanding its pathophysiology and immunological mechanisms. Apart from IgE-mediated atopic manifestations, T cell-mediated reactions have been demonstrated in infants with cow's milk allergy. The clinical spectrum ranges from immediate-type reactions, presenting with urticaria and angioedema to intermediate and late-onset reactions, including atopic dermatitis, infantile colic, gastro-oesophageal reflux, oesophagitis, infantile proctocolitis, food-associated enterocolitis and constipation. The exact mechanisms of these disorders are still poorly understood. Double-blind, placebo controlled food challenge, the definitive diagnostic test for cow's milk allergy, is increasingly being replaced by the measurement of food-specific antibodies, in combination with skin-prick or atopy patch testing. The treatment of cow's milk allergy relies on allergen avoidance and hypoallergenic formulae, or maternal elimination diets in breast-fed infants.
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Affiliation(s)
- Ralf G Heine
- Department of Allergy, Royal Children's Hospital, Parkville, Victoria, Australia.
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