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Meyer R, Vandenplas Y, Lozinsky AC, Vieira MC, Berni Canani R, du Toit G, Dupont C, Giovannini M, Uysal P, Cavkaytar O, Knibb R, Fleischer DM, Nowak-Wegrzyn A, Venter C. Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper. Pediatr Allergy Immunol 2024; 35:e14163. [PMID: 38825829 DOI: 10.1111/pai.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/10/2024] [Indexed: 06/04/2024]
Abstract
The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.
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Affiliation(s)
- Rosan Meyer
- Department of Nutrition and Dietetics, University of Winchester, Winchester, UK
- Department of Medicine, KU Leuven, Leuven, Belgium
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Adriana Chebar Lozinsky
- Department of Allergy and Immune Disorders, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Mario C Vieira
- 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
| | - George du Toit
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Christophe Dupont
- Department of Paediatric Gastroenterology, Necker University Children Hospital, Paris, France
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Pinar Uysal
- Department of Allergy and Clinical Immunology, Adnan Menderes University, Aydin, Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Faculty of Medicine, Goztepe Prof Suleyman Yalcin City Hospital, 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
- Icahn School of Medicine at Mount Sinai, Jaffe Food Allergy Institute, New York, New York, USA
| | - Carina Venter
- University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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2
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Tran KL, Wisner EL, Jeha GM, Wall LA. Development of IgE-mediated food allergies in children with history of food protein-induced allergic proctocolitis: a series of five cases. FRONTIERS IN ALLERGY 2024; 5:1354106. [PMID: 38650862 PMCID: PMC11033684 DOI: 10.3389/falgy.2024.1354106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 04/25/2024] Open
Abstract
Food protein-induced allergic proctocolitis (FPIAP) is a non-IgE-mediated allergic condition that presents with hematochezia in otherwise healthy infants. It is most commonly induced by cow's milk protein via breast milk or formula. The prognosis for FPIAP is generally considered favorable with most infants achieving symptomatic resolution after diet modification. Most infants go on to tolerate the offending foods by 1-3 years of age. Over 8 years at our institution, five patients were identified and noted to have FPIAP to cow's milk during infancy with subsequent development of IgE-mediated allergic reaction to cow's milk and other foods. All five cases developed other atopic disorders (atopic dermatitis in four cases). IgE-mediated cow's milk allergy has persisted beyond the preschool years in at least two patients (currently 8 and 16 years old). For three of the patients, the IgE-mediated reaction to cow's milk was severe with development of anaphylaxis or angioedema. In addition, three patients experienced anaphylaxis or angioedema to allergens other than milk. While FPIAP is a non-IgE-mediated process traditionally thought not to progress past the first year of life, some infants with FPIAP develop severe, persistent IgE-mediated cow's milk allergy. To our knowledge, this is the first detailed clinical description of such patients.
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Affiliation(s)
- Kim L. Tran
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States
| | - Elizabeth L. Wisner
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States
- Allergy and Immunology, Children’s Hospital of New Orleans, New Orleans, LA, United States
| | - George M. Jeha
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States
| | - Luke A. Wall
- School of Medicine, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA, United States
- Allergy and Immunology, Children’s Hospital of New Orleans, New Orleans, LA, United States
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3
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Venter C, Meyer R, Bauer M, Bird JA, Fleischer DM, Nowak-Wegrzyn A, Anagnostou A, Vickery BP, Wang J, Groetch M. Identifying Children at Risk of Growth and Nutrient Deficiencies in the Food Allergy Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:579-589. [PMID: 38280452 DOI: 10.1016/j.jaip.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Food allergies affect growth in children by decreasing the availability of nutrients through decreased dietary intake, increased dietary needs, food-medication interactions, and psychosocial burden. Guidelines on food allergy management frequently recommend nutrition counseling and growth monitoring of children with food allergies. OBJECTIVE To provide clear guidance for clinicians to identify children with food allergies who are at nutritional risk and ensure prompt intervention. METHODS We provide a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to identify those with food allergy at greatest nutritional risk, determine the impact of nutritional interventions on growth, and develop guidance for risk reduction in children with food allergies. RESULTS Children with food allergies are at increased risk of nutritional deficiencies and poor growth. Nutritional assessment and intervention can improve outcomes. Identifying poor growth is an important step in the nutrition assessment. Therefore, growth should be assessed at each allergy evaluation. Interventions to ensure adequate dietary intake for growth include appropriately prescribed elimination diets, breast-feeding support and assessment, supplemental formula, vitamin and/or mineral supplementation, appropriate milk substitutes, and timely introduction of nutrient-dense complementary foods. Access to foods of appropriate nutritional value is an ongoing concern. CONCLUSION Nutrition intervention or referral to registered dietitian nutritionists with additional training and/or experience in food allergy may result in improved growth and nutrition outcomes.
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Affiliation(s)
- Carina Venter
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado, Aurora, Colo.
| | - Rosan Meyer
- Department of Medicine, Imperial College London, London, United Kingdom; Department of Nutrition and Dietetics, University of Winchester, Winchester, United Kingdom; Department of Medicine, KU Leuven, Leuven, Belgium
| | - Maureen Bauer
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - J Andrew Bird
- Department of Pediatrics, Division of Allergy and Immunology, UT Southwestern Medical Center, Dallas, Texas
| | - David M Fleischer
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - Anna Nowak-Wegrzyn
- Hassenfeld Children's Hospital, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Aikaterini Anagnostou
- Section of Allergy and Immunology, Baylor College of Medicine, Houston, Texas; Section of Allergy and Immunology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Brian P Vickery
- Children's Healthcare of Atlanta, Atlanta, Ga; Department of Pediatrics, Emory University, Atlanta, Ga
| | - Julie Wang
- Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marion Groetch
- Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
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Vandenplas Y, Meyer R, Nowak-Wegrzyn A, Salvatore S, Venter C, Vieira MC. The Remaining Challenge to Diagnose and Manage Cow's Milk Allergy: An Opinion Paper to Daily Clinical Practice. Nutrients 2023; 15:4762. [PMID: 38004156 PMCID: PMC10675216 DOI: 10.3390/nu15224762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Guidelines and recommendations for the diagnosis and management of cow's milk allergy (CMA) in childhood are based on scientific review of the available evidence. While this approach is the most rigorous, guidelines may not fully address all scenarios encountered by clinicians. Many symptoms of CMA overlap with other common childhood illnesses and are subjectively reported by the caregivers of the infant, as is the interpretation of the dietary interventions. Additionally, many healthcare professionals and caregivers do not follow the recommendations to perform an oral food challenge or reintroduction of cow's milk after a diagnostic elimination diet because (1) the infant is doing well and (2) the carer's fear of symptoms relapsing with this procedure. As a result, CMA in infants may be either under-diagnosed leading to reduced quality of life for families or over-diagnosed, resulting in unnecessary long-term elimination diets and increasing the risk for nutritional deficiencies. This paper discusses some of these controversial topics, focusing on misdiagnosis and mismanagement in clinical practice. The lack of objective diagnostic criteria can hamper the diagnosis and management of CMA in daily practice.
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Affiliation(s)
- Yvan Vandenplas
- UZ Brussel, KidZ Health Castle, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
| | - Rosan Meyer
- Department Paediatrics, Imperial College London, London SW7 2BX, UK
- Department Dietetics, Winchester University, Winchester SO23 4NR, UK
- Department Medicine, KU Leuven, 3001 Leuven, Belgium
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children’s Hospital, New York, NY 10016, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Silvia Salvatore
- Department of Pediatrics, Hospital “F. Del Ponte”, University of Insubria, 21100 Varese, Italy;
| | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, University of Colorado, Aurora, CO 80045, USA
| | - Mario C. Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba 80250, Brazil;
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5
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Bahceci S, Töz PK, Celik FC, Can D. A different starting line for allergic march: food protein-induced allergic proctocolitis. Allergol Immunopathol (Madr) 2023; 51:40-45. [PMID: 37422778 DOI: 10.15586/aei.v51i4.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/30/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE The aim of this study is to investigate the long-term prognosis of food protein--induced allergic proctocolitis (FPIAP) patients, the risk of developing both allergic and gastrointestinal diseases, and to evaluate whether it leads to allergic march. METHODS A total of 149 children who were diagnosed with FPIAP and developed tolerance at least 5 years prior to the study and 41 children (with no history of food allergy) as a control group were enrolled. Both groups were re-evaluated for allergic diseases as well as gastrointestinal disorders. RESULTS The mean age of diagnosis for the FPIAP group was 4.2 ± 3.0 months, while the mean age of tolerance was 13.9 ± 7.7 months. The mean age of both FPIAP and control groups at the last visit was 101.6 ± 24.4 and 96.3 ± 24.1 months, respectively (P = 0.213). At the final evaluation of both groups, the comorbid allergic disease was significantly higher in the FPIAP group (P < 0.001). There was no significant difference between the two groups in terms of functional gastrointestinal disorders (FGIDs), eosinophilic gastrointestinal diseases, and inflammatory bowel disease (P = 0.198, 0.579, and 0.579, respectively).In the FPIAP group, the allergic disease was significantly higher at the final visit in patients with comorbid allergic disease at diagnosis (P < 0.001). In the FPIAP group, FGID was significantly higher in the group that developed allergic diseases in the future, compared to the group that did not develop allergic diseases in the future (P = 0.034). The proportion of both FGID and allergic diseases was significantly higher in subjects that developed tolerance at >18 months, compared to subjects that developed tolerance at >18 months (P < 0.001 and <0.001, respectively). CONCLUSIONS Patients with FPIAP may develop allergic diseases as well as FGID in the long term.
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Affiliation(s)
- Semiha Bahceci
- Department of Pediatric Allergy and Immunology, Çiğli Training and Research Hospital, Izmir Bakırçay University, Faculty of Medicine, Izmir, Turkey
| | - Pınar Kuyum Töz
- Department of Pediatric Gastroenterology, Çiğli Training and Research Hospital, Izmir, Turkey
| | - Figen Celebi Celik
- Department of Pediatric Allergy and Immunology, Dr Behcet Uz Children's Hospital, Izmir, Turkey;
| | - Demet Can
- Department of Pediatric Allergy and Immunology, Dr Behcet Uz Children's Hospital, Izmir, Turkey
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Kumar R, Gaur S, Agarwal M, Menon B, Goel N, Mrigpuri P, Spalgais S, Priya A, Kumar K, Meena R, Sankararaman N, Verma A, Gupta V, Sonal, Prakash A, Safwan MA, Behera D, Singh A, Arora N, Prasad R, Padukudru M, Kant S, Janmeja A, Mohan A, Jain V, Nagendra Prasad K, Nagaraju K, Goyal M. Indian Guidelines for diagnosis of respiratory allergy. INDIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY 2023. [DOI: 10.4103/0972-6691.367373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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7
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Wright K, Feeney M, Yerlett N, Meyer R. Nutritional Management of Children with Food Allergies. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00320-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Purpose of the Review
The purpose of the review is to review the evidence for the nutritional management of paediatric food allergy and provide a practical approach for healthcare professionals working in this area.
Recent Findings
Dietary elimination remains the mainstay for management of food allergies in children. However, the elimination of food allergens increases the risk for growth faltering, micronutrient deficiencies and feeding difficulties. Breastmilk remains the ideal source of nutrition for infants, but when not available, the vast majority will tolerate an extensively hydrolysed formula, and rice hydrolysate has also been suggested as a suitable alternative. Only in severe cases, including anaphylaxis, eosinophilic oesophagitis and growth faltering, is an amino acid formula indicated. The early introduction of peanut and egg and avoiding the delay in the introduction of other allergens, when not already allergic, has been highlighted by recent studies.
Summary
Whilst the elimination of allergens increases the risk of developing poor growth, micronutrient deficiencies and feeding difficulties, optimal, early dietary input, including advice on active introduction of allergens and alternative feeds, ideally from a registered dietitian/nutritionist, may be prevent and improve outcomes.
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8
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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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Connor F, Salvatore S, D’Auria E, Baldassarre ME, Acunzo M, Di Bella G, Farella I, Sestito S, Pensabene L. Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review. Nutrients 2022; 14:1317. [PMID: 35334974 PMCID: PMC8955686 DOI: 10.3390/nu14061317] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/02/2022] [Accepted: 03/17/2022] [Indexed: 12/11/2022] Open
Abstract
Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35-52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows' milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows' milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0-17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows' milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.
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Affiliation(s)
- Frances Connor
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children’s Hospital, Brisbane 4101, Australia;
- Mayne Academy of Pediatrics, Faculty of Medicine, University of Queensland, Brisbane 4101, Australia
| | - Silvia Salvatore
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy; (S.S.); (G.D.B.)
| | - Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.A.)
| | - Maria Elisabetta Baldassarre
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Miriam Acunzo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (E.D.); (M.A.)
| | - Gaia Di Bella
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy; (S.S.); (G.D.B.)
| | - Ilaria Farella
- Department of Biomedical Science and Human Oncology, Clinica Medica “A. Murri”, “Aldo Moro” University of Bari, 70124 Bari, Italy;
| | - Simona Sestito
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
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Sorensen K, Meyer R, Grimshaw KE, Cawood AL, Acosta-Mena D, Stratton RJ. The clinical burden of cow's milk allergy in early childhood: A retrospective cohort study. Immun Inflamm Dis 2022; 10:e572. [PMID: 34873874 PMCID: PMC8926503 DOI: 10.1002/iid3.572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/08/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Cow's milk allergy (CMA) is common in infants and children. Clinical presentations may vary, with a range of symptoms affecting the gastrointestinal (GI), skin and respiratory systems. Whilst the primary focus of research to date has been on the management of these symptoms, studies investigating the broader clinical burden of CMA are limited. Methods We performed a retrospective matched cohort study examining clinical data, including allergic symptoms and infections, extracted from case records within The Health Improvement Network database. A total of 6998 children (54% male) were included in the study, including 3499 with CMA (mean age at diagnosis 4.04 months) and 3499 matched controls without CMA, observed for a mean period of 4.2 years. Results GI, skin and respiratory symptoms affected significantly more children with CMA (p < .001), which recurred more often (p < .001), compared with children without CMA. More children with CMA had symptoms affecting multiple systems (p < .001). CMA was associated with a greater probability of these symptoms requiring hypoallergenic formula (HAF) prescription persisting over time (log‐rank test p < .0001, unadjusted hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.76–0.85, p < .001), with a longer median duration of symptoms and HAF prescription compared with the duration of symptoms in those without CMA (3.48 vs. 2.96 years). GI, skin, respiratory and ear infections affected significantly more children with CMA than those without, increasing by 74% (p < .001), 20% (p < .001), 9% (p < .001), and 30% (p < .001) respectively. These infections also recurred more often among children with CMA, increasing by 62% for GI infections, 37% for skin and respiratory infections, and 44% for ear infections (p < .001). Conclusions This real‐world study provides evidence to suggest that CMA presents a significant clinical burden to children, which has implications for the healthcare system. Further research is warranted to understand the health economic impact of this, and the phenotypes, factors and management approaches which may affect clinical outcomes.
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Affiliation(s)
| | - Rosan Meyer
- Department of Paediatrics, St. Mary's Hospital, London, UK
| | - Kate E Grimshaw
- Dietetic Department, Salford Care Organisation, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Human Nutrition, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Abbie L Cawood
- Medical Affairs, Nutricia Ltd., Trowbridge, UK.,Institute of Human Nutrition, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | | | - Rebecca J Stratton
- Medical Affairs, Nutricia Ltd., Trowbridge, UK.,Institute of Human Nutrition, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
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11
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Uncuoğlu A, Aydoğan M, Şimşek IE, Çöğürlü MT, Uçak K, Acar HC. A Prospective Assessment of Clinical Characteristics and Responses to Dietary Elimination in Food Protein-Induced Allergic Proctocolitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:206-214.e1. [PMID: 34737107 DOI: 10.1016/j.jaip.2021.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Some aspects of diagnostic elimination/challenge diets in food protein-induced allergic proctocolitis (FPIAP) are still poorly defined. OBJECTIVE This study investigated the symptom spectrum, time required for resolution of each symptom, triggering foods, and risk factors for multiple food allergies (MFA) in FPIAP. METHODS Infants referred with visible blood in stool were enrolled after etiologies other than FPIAP had been excluded. Laboratory evaluation, clinical features, and elimination/challenge steps were performed prospectively during diagnostic management. RESULTS Ninety-one of 102 infants (53 boys) were diagnosed with FPIAP. Eleven children did not bleed during challenges. Visible blood in stool began before 2 months of age in 63.6% of the infants not diagnosed with FPIAP, compared with 18.9% of the patients with FPIAP (P = .003). Offending foods were identified as cow's milk (94.5%), egg (37.4%), beef (10.9%), wheat (5.5%), and nuts (3.3%). MFA was determined in 42.9% of patients. Multivariate logistic regression analysis identified atopic dermatitis (AD) (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.18-7.55, P = .021) and an eosinophil count ≥300 cells/μL (OR: 2.72, 95% CI: 1.09-6.80, P = .032) as independent risk factors for MFA. Blood and mucus in stool disappeared in a median 3 days (interquartile range [IQR]: 1-14.5 days) and 30 days (IQR: 8-75 days), respectively. CONCLUSIONS A tendency to transient bleeding occurs in infants who present with bloody stool before 2 months of age. A 2-week duration of elimination for blood in stool is sufficient to reach a judgment of suspected foods for FPIAP. Mucus in stool is the last symptom to disappear. Concurrent AD suggests a high probability of MFA in FPIAP.
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Affiliation(s)
- Ayşen Uncuoğlu
- Division of Pediatric Gastroenterology Hepatology and Nutrition, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Metin Aydoğan
- Division of Pediatric Allergy and Immunology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey.
| | - Işıl Eser Şimşek
- Division of Pediatric Allergy and Immunology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Müjde Tuba Çöğürlü
- Division of Pediatric Allergy and Immunology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Kübra Uçak
- Department of Pediatrics, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Hazal Cansu Acar
- Department of Public Health, Cerrahpasa Faculty of Medicine, İstanbul University-Cerrahpasa, Istanbul, Turkey
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Meyer R, De Koker C, Dziubak R, Godwin H, Reeve K, Chebar-Lozinsky A, Foong RX, Skrapac AK, Ellmer M, Shah N. The Challenge of Home Allergen Re-introductions Using the Ladder Approach in Children With Non-IgE Mediated Gastrointestinal Food Allergy. FRONTIERS IN ALLERGY 2021; 2:721686. [PMID: 35386976 PMCID: PMC8974734 DOI: 10.3389/falgy.2021.721686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Oral food challenges remain the most reliable method for allergy confirmation. Although consensus guidelines have been published to unify Immunoglobulin E (IgE)-mediated challenges, this does not exist for non-IgE mediated gastrointestinal allergies outside of Food Protein Induced Enterocolitis Syndrome. We therefore set out to establish the use of home introduction protocols (HIP) for confirmation of food allergy for milk, soya, egg and wheat using a ladder approach in children with non-IgE mediated allergy. Materials and Methods: Patients with suspected non-IgE mediated gastrointestinal allergies (0–16 years) were recruited following symptom improvement on an elimination diet. All children had skin prick or specific IgE tests to rule out IgE-mediated allergies prior to suggestion the HIP. Number of trials and outcome was documented. HIPs were developed using a published ladder approach for cow's milk as baseline and final dose was calculated based on guidelines for food protein induced enterocolitis syndrome and portions for age from the National Diet and Nutrition Survey. First foods were baked/highly processed and every 4th day patients moved to a more unprocessed/unheated food. Results: From 131 recruited patients, 117 (89.3%) followed the HIP for food allergens. No adverse events were documented. In more than 50% of cases one attempt at the HIP was sufficient to establish allergy status, but many required 2–5 attempts before the outcome was clear. About half of the children were fully tolerant to foods they initially eliminated: 36, 26 and 30% were partially tolerant to milk, soya, and egg and only 15% achieved partial tolerance to wheat. Wheat was the allergen introduced earliest, followed by soya, cow's milk and egg. Conclusions: This study indicates that home HIPs are safe in non-IgE mediated gastrointestinal food allergy and that the ladder approach may be useful in re-introducing allergens in children at home with non-IgE mediated gastrointestinal allergies. From this study we can also conclude that tolerance to processed/baked allergens was observed in many children. Further studies should be performed on the HIP and ideally reintroduction should occur pre-defined time intervals.
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Affiliation(s)
- Rosan Meyer
- Department of Paediatric, Imperial College, London, United Kingdom
- *Correspondence: Rosan Meyer
| | - Claire De Koker
- Brackengate Intermediate Care Facility, Cape Town, South Africa
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Heather Godwin
- Frimley Health NHS Foundation Trust, Camberley, United Kingdom
| | - Kate Reeve
- Royal Hospital for Sick Children and Young People, Edinburgh, United Kingdom
| | | | - Ru-Xin Foong
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ana-Kristina Skrapac
- Department Nutrition and Dietetics, Chelsea and Westminster Hospital NHS Foundation Trust, Department of Nutrition and Dietetics, London, United Kingdom
| | - Marlene Ellmer
- Department of Gastroenterology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Neil Shah
- Department of Gastroenterology, University College London, UK and Reckitt, Slough, United Kingdom
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Sekkidou M, Muhardi L, Constantinou C, Kudla U, Vandenplas Y, Nicolaou N. Nutritional Management With a Casein-Based Extensively Hydrolysed Formula in Infants With Clinical Manifestations of Non-IgE-Mediated CMPA Enteropathies and Constipation. FRONTIERS IN ALLERGY 2021; 2:676075. [PMID: 35387002 PMCID: PMC8974831 DOI: 10.3389/falgy.2021.676075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The majority of mixed-fed infants with non-IgE-mediated cow's milk protein allergy (CMPA) enteropathies are managed with an extensively hydrolysed cow's milk based infant formula (eHF). Given the high variability in peptide distribution of available eHFs, it is important to understand the suitability of a specific product in the management of distinct phenotypes. Objective: To assess the symptom resolution of various phenotypes of clinical manifestations of CMPA enteropathies and constipation managed by a casein-based eHF. Methods: The data of 20 full-term infants (n = 15 with non-IgE-mediated CMPA and n = 5 with constipation) attending a paediatric allergy clinic in Cyprus and managed with a casein-based eHF were retrospectively analysed. Results: Based on the clinical symptoms and history, infants were classified into the following phenotypes: (a) 11/15 (73.3%) FPIAP, (b) 3/15 (20%) FPIES, and (c) 1/15 (6.7%) severe diarrhoea. Overall, 14 (93.3%) patients were successfully managed with the casein-based eHF and 1 (6.7%) required an AAF. This formula was effective in 91% of patients with FPIAP, in 100% with FPIES and with diarrhoea. Three (60%) patients with constipation responded to the eHF. Conclusion: This case-series report supports the efficacy of a particular casein-based eHF for the nutritional management of non-IgE mediated CMPA enteropathies.
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Affiliation(s)
| | - Leilani Muhardi
- Friesland Campina AMEA, Singapore, Singapore
- *Correspondence: Leilani Muhardi
| | | | | | - Yvan Vandenplas
- Kidz Health Castle University Hospital Brussels, Brussels, Belgium
| | - Nicolaos Nicolaou
- N Asthma and Allergy Center, Limassol, Cyprus
- University of Nicosia Medical School, Nicosia, Cyprus
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Ahmadipour S, Najafi M, Motamed F, Rahmani P. Feeding-based treatment of allergic proctocolitis and associated clinical outcomes. Clin Nutr ESPEN 2020; 40:237-241. [PMID: 33183543 DOI: 10.1016/j.clnesp.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Allergic colitis (AC) is one of the most common etiologies of rectal bleeding in infants aged one to six months. AIM The aim of this study is to apply step-by-step dietary restrictions in the mother's diet or change of infant formula fed thereby, to evaluate the subsequent clinical response. METHODS Sixty healthy infants whose clinical and evaluation results indicated proctocolitis in our outpatient gastroenterology clinic were included in this. They were divided into three groups according to the type of feeding; group 1 were exclusively breast fed, group 2 were exclusively formula fed and group 3 were fed with combination of both. In breast feeding women, discontinuation was allergenic food was studied in four stages; cow-related dairy products, soy, sesame and fast food (stage A), egg (stage B), corn, nuts and fish (stage C) and wheat (stage D). RESULTS Sixty newborns with age at symptom onset 3 days-20 days participated in the study. Up to the time of our initial evaluation, the mean age and weight of infants was 73.34 ± 1.00 day and 3292.71 ± 367.93 g, respectively. There was no significant difference in sex and the type of labor between the groups. Thirty-three infants had a history of eczema and the parents of 47 infants had a history of allergy, with the greatest prevalence in group one. Rectal bleeding in 50% of infants was halted after the elimination of allergenic feed in mother (15 in stage A, 8 in stage B and 7 in stage C). Ten infants needed extensive hydrolyzed formula and 20 needed amino acid-based formulas. CONCLUSIONS There is no need for immediate use of amino acid or extensive hydrolyzed formulas in the first stage of blood in stool, perhaps discontinuing allergenic food in mothers could be the primary measure.
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Affiliation(s)
- Shokoufeh Ahmadipour
- Department of Pediatrics, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran; Hepatitis Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran; Fellowship of Pediatrics Gastroenterology, Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehri Najafi
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Motamed
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Rahmani
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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16
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Kara M, Beser O, Konukoglu D, Cokugras H, Erkan T, Kutlu T, Cokugras F. The utility of TNF-α, IL-6 and IL-10 in the diagnosis and/or follow-up food allergy. Allergol Immunopathol (Madr) 2020; 48:48-55. [PMID: 31732222 DOI: 10.1016/j.aller.2019.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Several pro-inflammatory and anti-inflammatory mediators play a role in the immunopathogenesis of food allergy (FA). The aim of this study was to investigate the utility of serum biomarkers like interleukin (IL)-10, TNF-α, and IL-6 in the diagnosis and/or follow-up of FA. METHODS Sixty (25 females, 41.6%) newly diagnosed FA patients [IgE mediated (group-1, n=37), non-IgE (group-2, n=23)] with a median age of nine (1-33) months were enrolled. Twenty-four healthy children with a median age of eight (1-36) months constituted the control group (CG). In all the subjects, serum TNF-α, IL-6 and IL-10 levels were evaluated at the time of diagnosis and reassessed four weeks after therapeutic elimination diet (TED). RESULTS The mean white blood cell count and median absolute eosinophile count of the CG were significantly lower than group-1 (p values were 0.019 and 0.006, respectively). The mean absolute neutrophile count and the median IL-6 were significantly higher in group-1 when compared with group-2 (p values were 0.005 and 0.032, respectively. Median TNF-α and IL-6 levels were significantly higher in the pre-TED among all patients (p values were 0.005 and 0.018, respectively). In group-1, median TNF-α and IL-6 levels decreased significantly after TED (p values were 0.01 and 0.029, respectively). CONCLUSIONS Our findings support the role of inflammation in the pathogenesis of FA. Serum TNF-α and IL-6 levels may be useful markers for follow-up in FA, especially among IgE-mediated FA patients. Evaluation of IL-10 results was not sufficient for an interpretation of clinical tolerance.
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Meyer R, Chebar Lozinsky A, Fleischer DM, Vieira MC, Du Toit G, Vandenplas Y, Dupont C, Knibb R, Uysal P, Cavkaytar O, Nowak‐Wegrzyn A, Shah N, Venter C. Diagnosis and management of Non-IgE gastrointestinal allergies in breastfed infants-An EAACI Position Paper. Allergy 2020; 75:14-32. [PMID: 31199517 DOI: 10.1111/all.13947] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/16/2019] [Accepted: 04/20/2019] [Indexed: 12/14/2022]
Abstract
It is well-established that food proteins, such as egg, soya, cow's milk and wheat, are detectable in breastmilk for many hours or days after ingestion. Exposure to these proteins is important to the process of developing tolerance but can also sometimes elicit IgE-mediated and non-IgE-mediated allergic symptoms in breastfed infants. Non-IgE-mediated allergy, outside of food protein-induced allergic proctocolitis and eosinophilic oesophagitis, is not well understood, leading to variations in the diagnosis and management thereof. A primary objective of the European Academy for Allergy and Clinical Immunology is to support breastfeeding in all infants, including those with food allergies. A Task Force was established, to explore the clinical spectrum of non-IgE-mediated allergies, and part of its objectives was to establish diagnosis and management of non-IgE-mediated allergies in breastfed infants. Eight questions were formulated using the Patient, Intervention, Comparison, Outcome (PICO) system and Scottish Intercollegiate Guideline Network (SIGN) criteria for data inclusion, and consensus was achieved on practice points through the Delphi method. This publication aims to provide a comprehensive overview on this topic with practice points for healthcare professionals.
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Affiliation(s)
- Rosan Meyer
- Department Paediatrics Imperial College London London UK
| | - Adriana Chebar Lozinsky
- Department of Allergy and Immune Disorders Murdoch Children's Research Institute Melbourne Victoria Australia
| | - David M. Fleischer
- Children’s Hospital Colorado University of Colorado Denver School of Medicine Aurora CO USA
| | - Mario C. Vieira
- Department of Paediatrics, Pontifical Catholic University of Paraná, Center for Pediatric Gastroenterology Hospital Pequeno Príncipe Curitiba Brazil
| | - George Du Toit
- Department of Pediatric Allergy, Division of Asthma, Allergy and Lung Biology King’s College London and Guy’s and St. Thomas’ National Health Service Foundation Trust London UK
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel Vrije Universiteit Brussel Brussels Belgium
| | - Christophe Dupont
- Department of Paediatric Gastroenterology Necker University Children Hospital Paris France
| | - Rebecca Knibb
- Department of Psychology Aston University Birmingham UK
| | - Piınar Uysal
- Department of Allergy and Clinical Immunology Adnan Menderes University Aydin Turkey
| | - Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University, Medical Faculty Goztepe Training and Research Hospital Istanbul Turkey
| | - Anna Nowak‐Wegrzyn
- Icahn School of Medicine at Mount Sinai Jaffe Food Allergy Institute New York New York USA
| | - Neil Shah
- Department Gastroenterology Great Ormond Street Hospital London London UK
| | - Carina Venter
- Children’s Hospital Colorado University of Colorado Denver School of Medicine Aurora CO USA
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18
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Gholmie Y, Lozinsky A, Godwin H, Reeve K, Dzubiak R, Shah N, Meyer R. Tolerance of soya lecithin in children with non‐immunoglobulin E‐mediated soya allergy: a randomised, double‐blind, cross‐over trial. J Hum Nutr Diet 2019; 33:232-240. [DOI: 10.1111/jhn.12708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Y. Gholmie
- Department of Health and Behavioral Sciences Teachers College of Columbia University New York, NY USA
| | - A.C. Lozinsky
- Department of Gastroenterology Great Ormond Street Hospital for Children NHS Foundation Trust London UK
| | - H. Godwin
- Great Ormond Street Hospital London UK
| | - K. Reeve
- Paediatric A&E The Royal London Hospital London UK
| | | | - N. Shah
- Great Ormond Street Hospital London UK
| | - R. Meyer
- Imperial College London London UK
- Department Paediatrics Imperial College London London UK
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CONCENTRATIONS OF CYSTEINYL LEUKOTRIENES IN VARIOUS BIOLOGICAL FLUIDS OF CHILDREN WITH BRONCHIAL ASTHMA, ATOPIC DERMATITIS AND FOOD PROTEIN INDUCED ENTEROCOLITIS. EUREKA: HEALTH SCIENCES 2019. [DOI: 10.21303/2504-5679.2019.00945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Clinical manifestation of food allergy is characterized by polymorphic cutaneous, respiratory and gastrointestinal syndromes. Leukotrienes occupy a key place in the pathogenesis of a wide range of inflammatory diseases, including bronchial asthma, allergic rhinitis, atopic dermatitis, hives, allergic conjunctivitis, atherosclerotic cardio-vascular lesions system, inflammatory bowel disease, multiple sclerosis, cancer, etc. Better understanding of general pathophysiological mechanisms of allergic realization put the focus on the studying of cysteinyl leukotrienes biological effects in infants with atopic dermatitis and food-protein induced enterocolitis important.
Aim. To optimize the diagnosis of allergic lesions of the gastrointestinal tract in children.
Methods. The study was conducted in the allergy center and children clinic of the «Institute Pediatrics, Obstetrics and Gynecology named after academician O. Lukyanova of NAMS of Ukraine». Children were included from September 2017 to June 2018.
We examined 60 patients aged from 3 months to 3 years old, including 22 patients with atopic dermatitis, 18 children with food-protein induced enterocolitis, 8 patients with bronchial asthma in the stage of aggravation and 12 practically healthy children (control group).
Medical examination have been perfomed, general IG E and specific serum IG E were defined by ImmunoCAP (Phadia, 100), as well as concentrations of cysteinyl leukotrienes (LTB4, LTC4, LTE4) in biological liquids (serum, saliva, urine) using immunoenzyme method using the production sets of the "Enzolifescience" (USA) company on the analyzer-photometer Multiskan Plus "Labsystems". The results of the received data were processed statistically. The probability of differences was estimated with Student’s t-test and Tau Kendall rank correlation test. The difference was considered significant at p <0.05.
Results. A significant increase in the concentrations of cysteinyl leukotrienes (C4, D4, E4) in the blood, urine and saliva was found in infants with allergic skin diseases, gastro-intestinal and respiratory tract surveyed during manifestation the disease compared with the control group.
Comparison of concentrations of leukotrienes in urine and saliva of children with atopic dermatitis (AD), food-protein induced enterocolitis (FPIE) and asthma did not find credible. However, in the serum of patients with asthma, the concentration of cysteinyl leukotrienes was significantly higher (703.9±68.7) pg / ml than in children with enterocolitis induced by dietary proteins (509.3±57.4) pg / ml and significantly did not differ from patients with atopic dermatitis (695.2±46.3) pg / ml.
According to the results of Kendall Tau correlation test, no significant Spearman rank correlation was found between the cysteinyl leukotrienes concentration in blood and urine – r=0.14 (p>0.05), blood and saliva r=0.07 (p>0.05), urine and saliva r=–0.52 (p>0.05).
Conclusions. Increase in cysteinyl leukotrienes concentrations in serum, urine and saliva of children of early age with allergic skin diseases, respiratory and gastrointestinal tract was found. The absence of significant Spearman rank correlation between concentrations of leukotrienes in blood and urine, blood and saliva, saliva and urine shows that it is possible to select any biological fluid, saliva or urine, as a non-invasive way to determine the leukotriene concentrations for monitoring activity of allergic inflammation.
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Ludwig H, Krogulska A. [Food protein-induced enterocolitis syndrome (FPIES) - a rare disease with frequent symptoms - the practitioner's compendium]. DEVELOPMENTAL PERIOD MEDICINE 2019; 23. [PMID: 30954984 PMCID: PMC8522339 DOI: 10.34763/devperiodmed.20192301.6778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy with varying degrees of severity. The acute form of the disease is manifested by vomiting, lethargy and pallor, which usually appear within 1-4 hours after food ingestion, and can lead to shock. The most common trigger foods are: cow's milk, soy, rice and oats. Chronic FPIES is typical for infants fed with cow's milk or soy infant formula and is manifested by chronic vomiting, diarrhea and failure to thrive. In the vast majority of patients with FPIES, the analysis of the clinical history is sufficient to diagnose and identify trigger foods. If the history is unclear, use an oral food challenge to help confirm the diagnosis. Long-term management of patients with FPIES involves elimination of the trigger foods, monitoring for FPIES resolution and caregivers' education. The majority of children acquire food tolerance at the age of 3-5.
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Affiliation(s)
- Hanna Ludwig
- Katedra i Klinika Pediatrii, Alergologii i Gastroenterologii, Collegium Medicum im. Ludwika Rydygiera w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, ToruniuPolska,Hanna Ludwig Katedra i Klinika Pediatrii, Alergologii i Gastroenterologii, Collegium Medicum im. Ludwika Rydygiera Szpital Uniwersytecki nr 1 im. dr. A. Jurasza ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz tel. (+48 52) 585-48-50 faks (+48 52) 585-40-86
| | - Aneta Krogulska
- Katedra i Klinika Pediatrii, Alergologii i Gastroenterologii, Collegium Medicum im. Ludwika Rydygiera w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu, ToruniuPolska
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Chehade M, Meyer R, Beauregard A. Feeding difficulties in children with non-IgE-mediated food allergic gastrointestinal disorders. Ann Allergy Asthma Immunol 2019; 122:603-609. [PMID: 30922955 DOI: 10.1016/j.anai.2019.03.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To review the signs and symptoms of feeding difficulties in children with non-IgE-mediated food allergic gastrointestinal disorders and provide practical advice, with the goal of guiding the practitioner to timely referral for further evaluation and therapy. Various management approaches are also discussed. DATA SOURCES Articles and chapters related to normal feeding patterns and the diagnosis and management of feeding difficulties in children were reviewed. STUDY SELECTIONS Selections were based on relevance to the topic and inclusion of diagnostic and management recommendations. RESULTS Because most non-IgE-mediated food allergic gastrointestinal disorders occur in early childhood, feeding skills can be disrupted. Feeding difficulties can result in nutritional deficiencies, faltering growth, and a significant impact on quality of life. Specific symptoms related to each non-IgE-mediated food allergic gastrointestinal disorder can lead to distinctive presentations, which should be differentiated from simple picky eating. Successful management of feeding difficulties requires that the health care team views the problem as a relational disorder between the child and the caregiver and views its association with the symptoms experienced as a result of the non-IgE-mediated food allergic gastrointestinal disorder. Addressing the child's concern with eating needs to be done in the context of the family unit, with coaching provided to the caregiver as necessary while ensuring nutritional adequacy. Treatment approaches, including division of responsibility, food chaining, and sequential oral sensory, are commonly described in the context of feeding difficulties. CONCLUSION A multidisciplinary approach to management of feeding difficulties in non-IgE-mediated food allergic gastrointestinal disorders is of paramount importance to ensure success.
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Affiliation(s)
- Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Rosan Meyer
- Department of Pediatrics, Imperial College, London, England
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Meyer R, Fox AT, Chebar Lozinsky A, Michaelis LJ, Shah N. Non-IgE-mediated gastrointestinal allergies-Do they have a place in a new model of the Allergic March. Pediatr Allergy Immunol 2019; 30:149-158. [PMID: 30403301 DOI: 10.1111/pai.13000] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 10/08/2018] [Accepted: 10/23/2018] [Indexed: 12/18/2022]
Abstract
The rise in food allergy has been described as the "second wave" of the allergy epidemic, with some developed countries reporting a prevalence of 10% of challenge-proven food allergies. Recognition of the Allergic March has played a crucial role in identifying causality in allergic conditions, linking atopic dermatitis to food allergy and food allergy to other atopic disorders, thereby highlighting opportunities in prevention and the importance of early intervention. This publication will establish the value of weaving the less well-understood, non-IgE-mediated food allergy into the Allergic March and mapping its progression through childhood and its associated co-morbidities. The proposed non-IgE-mediated Allergic March highlights the concomitant presentation of gastrointestinal symptoms and atopic dermatitis as early presenting symptoms in confirmed non-IgE-mediated allergies and the later development of atopic co-morbidities, including asthma and allergic rhinitis, similar to the IgE-mediated Allergic March. This publication highlights recent observations of a link between non-IgE-mediated food allergy in early childhood and functional gastrointestinal disorders in later life and also the reported occurrence of extra-intestinal manifestations at later ages. Although significant limitations exist in regard to the proposed evolution of the Allergic March model, the authors hope that this publication will influence the management of non-IgE-mediated gastrointestinal allergies and inform future research and interventions.
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Affiliation(s)
- Rosan Meyer
- Department Paediatrics, Imperial College, London, UK
| | - Adam T Fox
- Department of Paediatric Allergy, Evelina London Children's Hospital, London, UK
| | | | - Louise J Michaelis
- Department of Allergy and Immunology, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Neil Shah
- Department Gastroenterology, Great Ormond Street Hospital, London, UK
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Emons JAM, Gerth van Wijk R. Food Allergy and Asthma: Is There a Link? CURRENT TREATMENT OPTIONS IN ALLERGY 2018; 5:436-444. [PMID: 30524933 PMCID: PMC6244552 DOI: 10.1007/s40521-018-0185-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose of review To describe and understand the links and interactions between food allergy and asthma. Recent findings Food allergy and asthma are characterized by an increasing prevalence. Moreover, food allergy and asthma often coexist. Both conditions are associated with each other in different ways. It has been shown that food allergy is a risk factor of developing asthma. Atopic dermatitis appears to be the common denominator in this interaction. Loss-of-function variants of the filaggrin mutation result in an impaired epidermal barrier function and have been shown to be a risk factor for the development of atopic dermatitis, allergies, and asthma. Early introduction of food allergens and optimal treatment of the skin barrier are preventive interventions for the development of food allergy and asthma. Asthma is also a risk factor for the development of severe or even fatal anaphylaxis in patients with food allergy. Isolated asthma is not a feature of a food allergic reaction; however, respiratory symptoms may be part of anaphylactic reactions. In addition, during an allergic reaction to food, non-specific bronchial hyperreactivity may increase. Cross-reactive allergens may be responsible for asthma-associated food allergy. This is particularly true for severe asthma upon ingestion of snail in patients allergic to house-dust mites. Finally, airborne allergens from occupational sources such as wheat, fish, and seafood may induce asthmatic reactions. This phenomenon is sometimes seen in non-occupational settings. Summary Food allergy and asthma are interconnected with each other beyond the presence of simple comorbidity. Food allergy precedes and predisposes to asthma, and mutual interactions range from respiratory symptoms and bronchial hyperreactivity during food-induced anaphylaxis to severe asthma due to cross-reactive food allergens and to occupational asthma upon exposure to airborne allergens. Moreover, coexisting asthma in food allergies may result in severe and sometimes fatal anaphylactic reactions.
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Affiliation(s)
- Joyce A M Emons
- 1Erasmus MC, Department of Pediatrics, Division of Respiratory Medicine and Allergology, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roy Gerth van Wijk
- 2Erasmus Medical Center, Department of Internal Medicine, Section of Allergology, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Meyer R, Groetch M, Venter C. When Should Infants with Cow's Milk Protein Allergy Use an Amino Acid Formula? A Practical Guide. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:383-399. [DOI: 10.1016/j.jaip.2017.09.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/04/2017] [Accepted: 09/16/2017] [Indexed: 12/18/2022]
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Erdem S, Nacaroglu H, Karaman S, Erdur C, Karkıner C, Can D. Tolerance development in food protein-induced allergic proctocolitis: Single centre experience. Allergol Immunopathol (Madr) 2017; 45:212-219. [PMID: 28159385 DOI: 10.1016/j.aller.2016.10.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/01/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Food protein-induced allergic proctocolitis (FPIAP) is characterised by inflammation of the distal colon in response to one or more food proteins. It is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. OBJECTIVE Our objective was to examine the clinical properties of patients with FPIAP, tolerance development time as well as the risk factors that affect tolerance development. METHODS The clinical symptoms, offending factors, laboratory findings, methods used in the diagnosis and tolerance development for 77 patients followed in the Paediatric Allergy and Gastroenterology Clinics with the diagnosis of FPIAP during January 2010-January 2015 were examined in our retrospective cross-sectional study. RESULTS The starting age of the symptoms was 3.3±4.7 months (0-36). Milk was found as the offending substance for 78% of the patients, milk and egg for 13% and egg for 5%. Mean tolerance development time of the patients was 14.7±11.9 months (3-66 months). Tolerance developed before the age of one year in 40% of the patients. Tolerance developed between the age of 1-2 years in 27%, between the age of 2-3 years in 9% and after the age of 3 years in 5% of the patients. CONCLUSIONS Smaller onset age and onset of symptoms during breastfeeding were found associated with early tolerance development. In the majority of the patients, FPIAP resolves before the age of one year, however in some of the patients this duration may be much longer.
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Meyer R, Godwin H, Dziubak R, Panepinto JA, Foong RXM, Bryon M, Lozinsky AC, Reeve K, Shah N. The impact on quality of life on families of children on an elimination diet for Non-immunoglobulin E mediated gastrointestinal food allergies. World Allergy Organ J 2017; 10:8. [PMID: 28261374 PMCID: PMC5320765 DOI: 10.1186/s40413-016-0139-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 12/22/2016] [Indexed: 01/22/2023] Open
Abstract
Background The impact on health related quality of life (HRQL) has been well studied in children with Immunoglobulin E (IgE)-mediated food allergy. However limited data exists on related quality of life (QOL) of families who have a child suffering from food protein induced non-IgE mediated gastrointestinal allergies. We aimed to establish the QOL of families with children at the beginning of following an elimination diet for non-IgE mediated gastrointestinal food allergies. Methods A prospective, observational study was performed. Parents of children aged 4 weeks–16 years who improved after 4–8 weeks of following an elimination diet for suspected non-IgE mediated allergies were included. The Family Impact Module (FIM) of the Pediatric Quality of Life (PedsQL™) was used and we compared our data to two historical cohorts: one with sickle cell disease and another with intestinal failure. Results One hundred and twenty three children with a median age of 20 months were included (84 boys). The total FIM Score was 57.43 (SD 22.27) and particularly low for daily activities and worry. Factors that impacted significantly included age (p < 0.0001), number of foods excluded (p = 0.008), symptom severity (p = 0.041) and chronic nasal congestion (p = 0.012). Children with non-IgE mediated food allergies had worse scores in all domains (p < 0.0001) compared to sickle cell disease and worse physical (p = 0.04), emotional (p = 0.04) and worry (p = 0.01) domains compared to intestinal failure. Conclusions This study found that parent QOL and family functioning was worse in those families who had a child on an elimination diet for non-IgE mediated allergies compared to those with sickle cell disease and intestinal failure, highlighting the impact this disease has on families.
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Affiliation(s)
- Rosan Meyer
- Department Paediatrics, Imperial College, London, UK
| | - Heather Godwin
- Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Robert Dziubak
- Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Julie A Panepinto
- Department of Pediatrics, Children's Hospital of Wisconsin Research Institute/Medical College of Wisconsin, Hematology/Oncology/Bone Marrow Transplantation, Milwaukee, WI USA
| | - Ru-Xin M Foong
- University College of London/Institute of Child Health, London, UK
| | - Mandy Bryon
- Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Adriana Chebar Lozinsky
- Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kate Reeve
- The Royal London Hospital, Paediatric A&E, Whitechapel Road, London, E1 1BB UK
| | - Neil Shah
- Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2017; 139:1111-1126.e4. [PMID: 28167094 DOI: 10.1016/j.jaci.2016.12.966] [Citation(s) in RCA: 356] [Impact Index Per Article: 50.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/07/2016] [Accepted: 12/21/2016] [Indexed: 01/22/2023]
Abstract
Food protein-induced enterocolitis (FPIES) is a non-IgE cell- mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high-quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence-based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.
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Foong RX, du Toit G, Fox AT. Asthma, Food Allergy, and How They Relate to Each Other. Front Pediatr 2017; 5:89. [PMID: 28536690 PMCID: PMC5422552 DOI: 10.3389/fped.2017.00089] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/10/2017] [Indexed: 11/17/2022] Open
Abstract
The association between atopic diseases is well known, and previous research has shown that having one atopic disease can predispose to having another. The link between asthma and food allergy has been well researched, but the exact relationship between the two atopic conditions is not fully understood. Food allergic infants are at increased risk for the development of asthma and are at risk of food-induced asthmatic episodes and also anaphylaxis. Having a diagnosis of both food allergy and asthma has also been shown to have an effect on the severity of a patient's disease including being at greater risk of severe asthmatic episodes. Therefore, understanding the relationship between these two conditions in order to treat and manage these children safely is crucial to clinicians.
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Affiliation(s)
- Ru-Xin Foong
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK.,Institute of Child Health, University College of London, London, UK
| | - George du Toit
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Adam T Fox
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
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Lozinsky AC, Meyer R, De Koker C, Dziubak R, Godwin H, Reeve K, Dominguez Ortega G, Shah N. Time to symptom improvement using elimination diets in non-IgE-mediated gastrointestinal food allergies. Pediatr Allergy Immunol 2015; 26:403-8. [PMID: 25963794 DOI: 10.1111/pai.12404] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The prevalence of food allergy has increased in recent decades, and there is paucity of data on time to symptom improvement using elimination diets in non-Immunoglobulin E (IgE)-mediated food allergies. We therefore aimed to assess the time required to improvement of symptoms using a symptom questionnaire for children with non-IgE-mediated food allergies on an elimination diet. METHODS A prospective observational study was performed on patients with non-IgE-mediated gastrointestinal food allergies on an elimination diet, who completed a questionnaire that includes nine evidence-based food allergic symptoms before and after the exclusion diet. The questionnaire measured symptoms individually from 0 (no symptom) to 5 (most severe) and collectively from 0 to 45. Children were only enrolled in the study if collectively symptoms improved with the dietary elimination within 4 or 8 weeks. RESULTS Data from 131 patients were analysed including 90 boys with a median age of 21 months [IQR: 7 to 66]. Based on the symptom questionnaire, 129 patients (98.4%) improved after 4-week elimination diet and only two patients improved after 8 weeks. A statistically significant difference before and after commencing the elimination diet was seen in all nine recorded symptoms (all p < 0.001), and in the median of overall score (p < 0.001). CONCLUSION This is the first study attempting to establish time to improve after commencing the diet elimination. Almost all children in this study improved within 4 weeks of following the elimination diet, under dietary supervision.
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Affiliation(s)
- Adriana Chebar Lozinsky
- Department of Gastroenterology, Great Ormond Street Hospital for Children NHS foundation Trust, London, UK
| | - Rosan Meyer
- Department of Gastroenterology, Great Ormond Street Hospital for Children NHS foundation Trust, London, UK
| | - Claire De Koker
- Department Nutrition and Dietetics, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital for Children NHS foundation Trust, London, UK
| | - Heather Godwin
- Department of Gastroenterology, Great Ormond Street Hospital for Children NHS foundation Trust, London, UK
| | - Kate Reeve
- Department of Gastroenterology, Great Ormond Street Hospital for Children NHS foundation Trust, London, UK
| | | | - Neil Shah
- Department of Gastroenterology, Great Ormond Street Hospital for Children NHS foundation Trust, London, UK.,Institute of Child Health, University College London, London, UK
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Cow's Milk Protein Allergy from Diagnosis to Management: A Very Different Journey for General Practitioners and Parents. CHILDREN-BASEL 2015; 2:317-29. [PMID: 27417366 PMCID: PMC4928770 DOI: 10.3390/children2030317] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 07/01/2015] [Accepted: 07/13/2015] [Indexed: 12/23/2022]
Abstract
Cow’s milk protein allergy (CMPA) is the most common food allergy in infants and can affect a family’s quality of life. The purpose of this paper is to evaluate the knowledge and experience of general practitioners (GPs) in terms of CMPA diagnosis and management and to explore the views of parents on the current diagnostic process. Two surveys were conducted in June 2014, which collected data from GPs and parents of infants diagnosed with CMPA in the United Kingdom. The questionnaires included quantitative and qualitative questions, which measured self-reported knowledge, management and perceived treatment progression, and the educational needs of GPs. We also explored parents’ experiences of local healthcare support in relation to CMPA. A total of 403 GPs and 300 parents completed the surveys. The main symptoms of CMPA and diagnosis period differed between GPs and parents. Other key points include different perceptions on symptom presentation and improvement, lack of awareness from GPs about current guidelines, and the significant burden on both families and GPs. This is the first study attempting to establish GP and parental experience in diagnosing CMPA. It isnotable that the difference can be improved through training, appropriate diagnostic tools and improved communication between physicians and parents.
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Kaya A, Toyran M, Civelek E, Misirlioglu E, Kirsaclioglu C, Kocabas CN. Characteristics and Prognosis of Allergic Proctocolitis in Infants. J Pediatr Gastroenterol Nutr 2015; 61:69-73. [PMID: 26039942 DOI: 10.1097/mpg.0000000000000767] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The dietary protein proctocolitis, also known as allergic proctocolitis (AP), is characterized by the presence of mucoid, frothy, and bloody stools in an otherwise healthy infant. The aim of this study was to describe a group of children with AP, diagnosed according to the criterion-standard method, food challenge to provide clinicians with more information on typical presentation, and an overview on nutritional management strategies and prognosis. METHODS We collected data on infants with AP in our allergy and gastroenterology outpatient clinics. Any other conditions that may cause bloody diarrhea were ruled out. Skin prick tests and atopy patch tests were performed for diagnosis, and patients were studied for resolution. To the patients whose rectal bleeding did not recover with oligoantigenic maternal diet in addition to amino acid-based formula, endoscopic evaluation was performed to confirm the diagnosis and to exclude other reasons of rectal bleeding. RESULTS Sixty patients were diagnosed as having AP. The age of onset was 1.7 ± 1.32 months. All of the patients were triggered by milk, 6.6% with milk and egg, 3.3% with milk and chicken, 1.7% with milk and wheat, 1.7% with milk and potato, and 3.3% had multiple food allergy. 53.3% (n = 32) acquired tolerance by age 1, 25.0% (n = 15) by 2 years, 5% (n = 3) by 3, and 1.7% (n = 1) by 4 years. CONCLUSIONS Milk was a triggering factor for all of the patients. Resolution of AP is usually within 1 year but symptoms of some patients may continue even longer. An extension of the follow-up period is required according to our study.
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Affiliation(s)
- Aysenur Kaya
- *Department of Pediatric Allergy and Immunology †Department of Pediatric Gastroenterology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara ‡Department of Pediatric Allergy and Immunology, Mugla Sıtkı Kocman University, Mugla, Turkey
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Shah N, Foong RXM, Borrelli O, Volonaki E, Dziubak R, Meyer R, Elawad M, Sebire NJ. Histological findings in infants with Gastrointestinal food allergy are associated with specific gastrointestinal symptoms; retrospective review from a tertiary centre. BMC Clin Pathol 2015; 15:12. [PMID: 26085814 PMCID: PMC4469460 DOI: 10.1186/s12907-015-0012-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/05/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Gastrointestinal food allergy (GIFA) occurs in 2 to 4 % of children, the majority of whom are infants (<1 year of age). Although endoscopy is considered the gold standard for diagnosing GIFA, it is invasive and requires general anaesthesia. Therefore, we aimed to investigate whether in infants with GIFA, gastrointestinal symptoms predict histological findings in order to help optimise the care pathway for such patients. METHODS All infants <1 year of age over a 20 year period who underwent an endoscopic procedure gastroscopy or colonoscopy for GIFA were evaluated for the study. Symptoms at presentation were reviewed and compared with mucosal biopsy histological findings, which were initially broadly classified for study purposes as "Normal" or "Abnormal" (defined as the presence of any mucosal inflammation by the reporting pathologist at the time of biopsy). RESULTS Of a total of 1319 cases, 544 fitted the inclusion criteria. 62 % of mucosal biopsy series in this group were reported as abnormal. Infants presenting with diarrhoea, rectal (PR) bleeding, irritability and urticaria in any combination had a probability >85 % (OR > 5.67) of having abnormal histological findings compared to those without. Those with isolated PR bleeding or diarrhoea were associated with 74 % and 68 % probability (OR: 2.85 and 2.13) of an abnormal biopsy, respectively. Conversely, children presenting with faltering growth or reflux/vomiting showed any abnormal mucosal histology in only 50.8 % and 45.3 % (OR: 1.04 and 0.82) respectively. CONCLUSIONS Food allergy may occur in very young children and is difficult to diagnose. Since endoscopy in infants has significant risks, stratification of decision-making may be aided by symptoms. At least one mucosal biopsy demonstrated an abnormal finding in around half of cases in this selected population. Infants presenting with diarrhoea, PR bleeding, urticaria and irritability are most likely to demonstrate abnormal histological findings.
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Affiliation(s)
- Neil Shah
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom.,Institute of Child Health/UCL, London, WC1N 1EH UK
| | - Ru-Xin Melanie Foong
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Osvaldo Borrelli
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Eleni Volonaki
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Robert Dziubak
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Rosan Meyer
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Mamoun Elawad
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Neil J Sebire
- Histopathology Department, Great Ormond Street Hospital, London, United Kingdom
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Anagnostou K, Meyer R, Fox A, Shah N. The rapidly changing world of food allergy in children. F1000PRIME REPORTS 2015; 7:35. [PMID: 25926986 PMCID: PMC4371379 DOI: 10.12703/p7-35] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Food allergy is a common problem in childhood. The term is used to include both immunoglobulin E (IgE)-mediated and non-IgE-mediated food allergies, which have a significant effect on the quality of life of patients and their families. In this report, we aim to discuss recent advances in the diagnosis, management, and treatment modalities of food allergy in children.
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Affiliation(s)
- Katherine Anagnostou
- Department of Paediatric Allergy, Guy's and St Thomas' Hospitals NHS Foundation TrustWestminster Bridge Road, London, SE1 7EHUK
| | - Rosan Meyer
- Department of Paediatric Gastroenterology, Great Ormond Street Children's HospitalLondon, WC1N 3JHUK
| | - Adam Fox
- Department of Paediatric Allergy, Guy's and St Thomas' Hospitals NHS Foundation TrustWestminster Bridge Road, London, SE1 7EHUK
| | - Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Children's HospitalLondon, WC1N 3JHUK
- KULeuvenTargid - Herestraat 49, O&N1, Box 701 - 3000 LeuvenBelgium
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Skypala IJ, Venter C, Meyer R, deJong NW, Fox AT, Groetch M, Oude Elberink JN, Sprikkelman A, Diamandi L, Vlieg-Boerstra BJ. The development of a standardised diet history tool to support the diagnosis of food allergy. Clin Transl Allergy 2015; 5:7. [PMID: 25741437 PMCID: PMC4349299 DOI: 10.1186/s13601-015-0050-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/30/2015] [Indexed: 01/26/2023] Open
Abstract
The disparity between reported and diagnosed food allergy makes robust diagnosis imperative. The allergy-focussed history is an important starting point, but published literature on its efficacy is sparse. Using a structured approach to connect symptoms, suspected foods and dietary intake, a multi-disciplinary task force of the European Academy of Allergy and Clinical Immunology developed paediatric and adult diet history tools. Both tools are divided into stages using traffic light labelling (red, amber and green). The red stage requires the practitioner to gather relevant information on symptoms, atopic history, food triggers, foods eaten and nutritional issues. The amber stage facilitates interpretation of the responses to the red-stage questions, thus enabling the practitioner to prepare to move forward. The final green stage provides a summary template and test algorithm to support continuation down the diagnostic pathway. These tools will provide a standardised, practical approach to support food allergy diagnosis, ensuring that all relevant information is captured and interpreted in a robust manner. Future work is required to validate their use in diverse age groups, disease entities and in different countries, in order to account for differences in health care systems, food availability and dietary norms.
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Affiliation(s)
| | - Carina Venter
- The David Hide 6. Asthma and Allergy Research Centre, Isle of Wight, UK
| | - Rosan Meyer
- Great Ormond Street NHS Foundation Trust, London, UK
| | | | - Adam T Fox
- Guy's and St Thomas' Hospitals NHS Foundation Trust and Kings College, London, UK
| | - Marion Groetch
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - J N Oude Elberink
- Department of Allergology, University Medical Centre of Groningen, University of Groningen, Groningen, NL Netherlands
| | - Aline Sprikkelman
- Emma Children's Hospital Academic Medical Centre, Amsterdam, NL Netherlands
| | | | - Berber J Vlieg-Boerstra
- Emma Children's Hospital, Paediatric Respiratory Medicine and Allergy, Academic Medical Centre, University of Amsterdam, Amsterdam, NL Netherlands
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Abstract
Purpose of review To assess all the possible differential diagnosis of food protein-induced enterocolitis syndrome (FPIES), both in acute and chronic presentation, reviewing the data reported in published studies. Recent findings There is an increase of reported cases of FPIES in recent years. As the disease presents with nonspecific symptoms, it can be misunderstood in many ways. The differential diagnosis includes, in acute presentations, the following: sepsis, other infectious diseases, acute gastrointestinal episodes, surgical emergencies, food allergies. In its chronic forms, FPIES may mimic malabsorption syndromes, metabolic disorders, primary immunodeficiencies, neurological conditions, coagulation defects, and other types of non-IgE-mediated food allergy. Summary A thorough clinical evaluation, including symptoms, signs, and laboratory findings, is necessary to lead the clinicians toward the diagnosis of FPIES. The major reason for delayed diagnosis appears to be the lack of knowledge of the disease.
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Cristofori F, Arezzo F, Gentile A, Francavilla R. Gluten Sensitivity in Pediatrics: A Clinical Conundrum. CURRENT PEDIATRICS REPORTS 2014. [DOI: 10.1007/s40124-014-0053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Miceli Sopo S, Arena R, Greco M, Bergamini M, Monaco S. Constipation and Cow's Milk Allergy: A Review of the Literature. Int Arch Allergy Immunol 2014; 164:40-5. [DOI: 10.1159/000362365] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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