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Moak R, Boone N, Eidson N, Rohrer A, Engevik M, Williams K, Chetta K. Exploring the links between necrotizing enterocolitis and cow's milk protein allergy in preterm infants: a narrative review. Front Pediatr 2023; 11:1274146. [PMID: 38027265 PMCID: PMC10663262 DOI: 10.3389/fped.2023.1274146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
A broad range of allergic disorders and intolerance are associated with cow's milk protein in the infant diet. Allergy and intolerance to cow's milk proteins are commonly recognized in the healthy term infant, and the prevalence cow's milk protein intolerance (CMPI) varies widely but 5 challenge confirmed studies free from selection bias ranged from 1.9%-4.9%. These disorders are classified by the presence of IgE, non-IgE or T-cell-mediated signaling. Additionally, the severity of these adverse food reactions can range from mild gastrointestinal symptoms to severe sepsis-like episodes, as in the case of food protein-induced enterocolitis syndrome (FPIES). Food protein-induced intolerance in the healthy young infant lies in stark contrast to enterocolitis that typically occurs in the preterm neonate. Necrotizing enterocolitis (NEC) is a distinct progressive disease process, usually characterized by a high mortality rate, with a risk of death from 30% to 50%. While its exact etiology is unclear, its main triggers include formula (cow's milk protein), hypoxia, perfusion-related issues, and unregulated inflammation in the premature intestine. The distinction between NEC and cow's milk protein intolerance is difficult to discern in some cases. In the late preterm population, infants with colitis can have both NEC and cow's milk intolerance on the differential. In infants with multiple episodes of mild NEC, cow's milk protein intolerance may be the underlying diagnosis. In this review, we compare the pathophysiological characteristics, diagnosis and treatment of disorders of cow's milk protein intolerance with the entity of preterm NEC. This review highlights similarities in both entities and may inspire future cross-disciplinary research.
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Affiliation(s)
- Rosemary Moak
- Department of Internal Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Neal Boone
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Natalie Eidson
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Allison Rohrer
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Mindy Engevik
- Department of Regenerative Medicine & Cell Biology, Medical University of South Carolina, Charleston, SC, United States
- Department of Microbiology & Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Kelli Williams
- Department of Pediatrics, Division of Pediatric Pulmonology, Allergy and Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Katherine Chetta
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Charleston, SC, United States
- C.P. Darby Children’s Research Institute, Medical University of South Carolina, Shawn Jenkins Children’s Hospital, Charleston, SC, United States
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Florquin M, Eerdekens A. What is Known About Cow's Milk Protein Allergy in Preterm Infants? Breastfeed Med 2023; 18:767-778. [PMID: 37856666 DOI: 10.1089/bfm.2023.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Background: Cow's milk protein allergy (CMPA) is well described in term infants, as opposed to preterm infants. In preterm infants, CMPA shares many gastrointestinal symptoms with necrotizing enterocolitis (NEC). Objectives: To evaluate the presentation of CMPA in preterm infants and to investigate the different diagnostic and therapeutic options. Materials and Methods: We searched for the relevant literature using the medical databases PubMed, Web of Science, and the Cochrane Library. We performed a post hoc analysis on the 25 case reports included in this study. Results: Literature was scarce and heterogeneous. The majority of preterm infants with CMPA were exposed to bovine-based milk proteins before the development of symptoms. The most common clinical manifestations were bloody stools, vomiting, and abdominal distension. Of the 25 cases, only 7 (28%) retained human milk in their diet after diagnosis. In the larger studies, no study has human milk as primary feeding choice after diagnosis. Conclusions: Preterm infants exposed to a type of cow's milk-based formula in their first days of life have a higher risk of developing CMPA. Most of the preterm infants are no longer fed with human milk after the diagnosis of CMPA is made, which is in contrast with current nutrition guidelines in preterm infants. We strongly advocate that human milk with mothers on a cow's milk-free diet is the first choice of feed after the diagnosis of CMPA. Prospective studies are necessary to obtain more information regarding clinical presentation, diagnostic tools, and therapeutic approaches.
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Affiliation(s)
- Mona Florquin
- Department of Pediatrics and University Hospital Leuven, KU Leuven, Belgium
| | - An Eerdekens
- Department of Neonatology, University Hospital Leuven, KU Leuven, Belgium
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Al-Beltagi M, Saeed NK, Bediwy AS, Elbeltagi R. Cow’s milk-induced gastrointestinal disorders: From infancy to adulthood. World J Clin Pediatr 2022; 11:437-454. [PMID: 36439902 PMCID: PMC9685681 DOI: 10.5409/wjcp.v11.i6.437] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022] Open
Abstract
Milk is related to many gastrointestinal disorders from the cradle to the grave due to the many milk ingredients that can trigger gastrointestinal discomfort and disorders. Cow’s milk protein allergy (CMPA) is the most common food allergy, especially in infancy and childhood, which may persist into adulthood. There are three main types of CMPA; immunoglobulin E (IgE)-mediated CMPA, non-IgE-mediated CMPA, and mixed type. CMPA appears before the first birthday in almost all cases. Symptoms may start even during the neonatal period and can be severe enough to simulate neonatal sepsis. CMPA (often non-IgE mediated) can present with symptoms of gastroesophageal reflux, eosinophilic esophagitis, hemorrhagic gastritis, food protein-induced protein-losing enteropathy, and food protein-induced enterocolitis syndrome. Most CMPAs are benign and outgrown during childhood. CMPA is not as common in adults as in children, but when present, it is usually severe with a protracted course. Lactose intolerance is a prevalent condition characterized by the development of many symptoms related to the consumption of foods containing lactose. Lactose intolerance has four typical types: Developmental, congenital, primary, and secondary. Lactose intolerance and CMPA may be the underlying pathophysiologic mechanisms for many functional gastrointestinal disorders in children and adults. They are also common in inflammatory bowel diseases. Milk consumption may have preventive or promoter effects on cancer development. Milk may also become a source of microbial infection in humans, causing a wide array of diseases, and may help increase the prevalence of antimicrobial resistance. This editorial summarizes the common milk-related disorders and their symptoms from childhood to adulthood.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
- Department of Pediatrics, University Medical Center, Arabian Gulf University, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Department of Pathology, Microbiology Section, Salmaniya Medical Complex, Manama 26671, Bahrain
- Department of Pathology, Microbiology Section, Royal College of Surgeons in Ireland - Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Chest Diseases, University Medical Center, Arabian Gulf University, Manama 26671, Bahrain
| | - Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
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Ozdogan E, Caglayan LD, Mizikoglu O, Arikan C. Upper Gastrointestinal Bleeding as the First Presentation of Eosinophilic Gastrointestinal Disease. JPGN REPORTS 2020; 1:e017. [PMID: 37206599 PMCID: PMC10191568 DOI: 10.1097/pg9.0000000000000017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/08/2020] [Indexed: 05/21/2023]
Abstract
Gastrointestinal bleeding is a rare but potentially life-threatening manifestation of eosinophilic gastrointestinal disorders (EGIDs). Here, we describe a case series comprising 5 pediatric patients between 7 and 12 years of age, who presented to the emergency department with hematemesis and were subsequently diagnosed with EGID. Accompanying allergic history, peripheral eosinophilia, and total IgE elevation were common. Despite a more severe presentation, response to medical and dietary therapy was favorable. A comprehensive review of the literature revealed 26 other cases with similar findings that reinforced the importance of prompt recognition and early dietary and immunomodulating therapy in the control of this disease.
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Affiliation(s)
- Elif Ozdogan
- From the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Koc University School of Medicine, Istanbul, Turkey
| | | | - Ozlem Mizikoglu
- Organ Transplantation Center, Liver Transplantation, Koc University School of Medicine, Istanbul, Turkey
| | - Cigdem Arikan
- From the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Koc University School of Medicine, Istanbul, Turkey
- Organ Transplantation Center, Liver Transplantation, Koc University School of Medicine, Istanbul, Turkey
- Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey
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Yokoyama S, Nakaoka T, Nukada T, Ikeda Y, Hara S. Neonatal eosinophilic gastroenteritis mimicking hypertrophic pyloric stenosis. Pediatr Int 2020; 62:99-101. [PMID: 31997530 DOI: 10.1111/ped.14041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/19/2019] [Accepted: 09/25/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Satoshi Yokoyama
- Department of Pediatric surgery, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan
| | - Tatsuo Nakaoka
- Department of Pediatric surgery, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan
| | - Takayuki Nukada
- Department of Pediatrics, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan
| | - Yuka Ikeda
- Department of Pediatrics, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan
| | - Shigeto Hara
- Department of Pediatrics, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan
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Ferretti E, Pilon S, Boland M, El Demellawy D. Early Onset Allergic Proctitis in a Preterm Neonate-A Case Report and Review of the Literature. Pediatr Dev Pathol 2019; 22:152-156. [PMID: 30286677 DOI: 10.1177/1093526618803770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cow's milk protein allergy/intolerance (CMPA/CMPI) is a common entity in the pediatric population with a nonspecific presentation ranging from gastrointestinal symptoms to systemic manifestations. Most infants with CMPI are term, and symptoms often appear in the week following the introduction of cow's milk-based formula. There is typically a significant delay in the onset of milk allergy in premature infants compared to full term. We report a rare case of a premature neonate who presented with symptoms of CMPA within the first 2 days of life.
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Affiliation(s)
- Emanuela Ferretti
- 1 Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,2 Division of Newborn Care, The Ottawa Hospital-General Campus, University of Ottawa, Ottawa, Canada.,3 Department of Pediatrics, Division of Gastroenterology, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Sarah Pilon
- 4 Developmental Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Margaret Boland
- 3 Department of Pediatrics, Division of Gastroenterology, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Dina El Demellawy
- 3 Department of Pediatrics, Division of Gastroenterology, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.,5 Department of Pathology, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Tanaka K, Koshida S, Yanagi T, Tsutsui H, Nakahara S, Furukawa O, Tsuji S. Suspected fetal onset of neonatal transient eosinophilic colitis and development of respiratory distress. Pediatr Int 2015; 57:734-8. [PMID: 25809522 DOI: 10.1111/ped.12577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 11/07/2014] [Accepted: 11/17/2014] [Indexed: 11/29/2022]
Abstract
Neonatal transient eosinophilic colitis (NTEC) is a new disease concept within eosinophilic gastroenteritis, which was proposed by Ohtsuka et al. It causes hematochezia as a result of eosinophilia, in neonates who have not yet started to receive enteral nutrition, although the whole-body status of the infant is in fact relatively good. To date, there have been no reports of this disease in which abnormalities were noted during gestation, and the clinical phenomena surrounding it, along with any complications, are not yet clear. We encountered a suspected case of NTEC causing respiratory distress with aspiration of hematochezia, in which dilated bowel was noted during gestation. This case indicates that NTEC may occur at the fetal stage and be complicated by respiratory distress.
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Affiliation(s)
- Katsunori Tanaka
- Department of Pediatrics, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Shigeki Koshida
- Department of Pediatrics, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Takahide Yanagi
- Department of Pediatrics, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Hidemi Tsutsui
- Department of Pediatrics, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Sayuri Nakahara
- Department of Pediatrics, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Ouki Furukawa
- Department of Pediatrics, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science Hospital, Otsu, Shiga, Japan
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Choi BS, Hong SJ, Park SH, Kim HM, Choe BH. Differences in Features and Course of Mucosal Type Eosinophilic Gastroenteritis between Korean Infants and Children. J Korean Med Sci 2015; 30:1129-35. [PMID: 26240491 PMCID: PMC4520944 DOI: 10.3346/jkms.2015.30.8.1129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/09/2015] [Indexed: 12/19/2022] Open
Abstract
Eosinophilic gastroenteritis (EGE) is a disorder characterized by eosinophilic infiltration of the bowel wall and various gastrointestinal (GI) manifestations. This study aimed to evaluate the characteristics of EGE in infants and children. A total of 22 patients were diagnosed with histologic EGE (hEGE) or possible EGE (pEGE). Serum specific IgE levels, peripheral eosinophil counts, and endoscopic biopsies were carried out. In the hEGE group (n = 13), initial symptoms included hematemesis, abdominal pain, and vomiting. Three of the subjects had normal endoscopic findings. Eight patients were categorized into the infant group and 5 into the child group. All patients in the infant group showed clinical improvement after switching from cow's milk feeding to special formula or breast feeding. The infant group showed a higher eosinophil count in the gastric mucosal biopsy than the child group. In the pEGE group (n = 9) initial symptoms included hematemesis, abdominal pain, and vomiting. Seven patients in this group showed a good response to treatment with restriction of the suspected foods and/or the administration of ketotifen. Both hEGE and pEGE groups showed clinical improvement after restriction of suspected foods in the majority of cases and also showed a similar clinical course. EGE should be considered in the differential diagnosis of patients with chronic abdominal pain, vomiting, and hematemesis of unknown cause. The infant group may have a better prognosis than the child group if treated properly.
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Affiliation(s)
- Bong Seok Choi
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Suk Jin Hong
- Department of Pediatrics, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Suk Hyun Park
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Heng Mi Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Byung-Ho Choe
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
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