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PRACTICAL APPLICATION OF
NUTRITION IN PATIENTS WITH
FOOD ALLERGY
John T. Stutts, MD, MPH
Division of Pediatric Gastroenterology
University of Louisville School of Medicine
Louisville, Kentucky
DISCLOSURE
• Support for this program is provided
by Abbott Nutrition
• The slides were developed by the
Speaker with input by Abbott Nutrition
• This program is not intended for
continuing education credits for any
healthcare professional
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ADVERSE FOOD REACTIONS
• Any abnormal clinical response associated with
ingestion of or exposure to a food or food additive
• Up to 25% of the US population report a symptom
related to a food
- Most cannot be confirmed
• Events where food relation can be confirmed can
be further classified as:
- Food intolerance
- Food Allergy
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Adverse Food Reaction
Food Intolerance
Food
Characteristics
Host
Characteristics
Graphic adapted from Reference 1
Food Allergy
IgE
mediated
Non-IgE
mediated
Mixed
COW’S MILK PROTEIN ALLERGY
(CMPA)
• What is it?
- The most common food allergy
present in up to ~ 2.5-3% of
otherwise normal infants within
the first year of life2.
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IGE-MEDIATED AND NON-IGE
MEDIATED MILK ALLERGY IN INFANTS
• IgE-mediated
- Several systems involved: rarely an isolated gut
syndrome
- Most often in an infant with atopic dermatitis
• Non-IgE- mediated
- More common in first part of first year
- Symptoms usually affect gut only
- Food protein-induced enterocolitis syndrome
(FPIES)
- Allergic proctocolitis (CMPA)
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COW’S MILK PROTEIN
ALLERGY
How does it manifest?
Gastrointestinal
50 – 60%
• Blood/mucus in
stool
• Abdominal pain
• Iron deficiency
anemia
• Hypoalbuminemia
• Failure to thrive
(DIV)
Skin
50 – 60%
• Atopic dermatitis
• Urticaria
Respiratory Tract
20 – 30%
• Acute
Laryngoedema
• Obstruction with
difficulty breathing
• Anaphylaxis
Reference 3.
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WHAT TESTS SHOULD I
CONSIDER FOR CMPA?
• Generally tests are not needed
• Wright stain: may be + neutrophils and possibly
eosinophils
• Stool culture: Staphylococcus aureus, enteric
pathogens, C. difficile
• Blood tests
- Complete blood count (CBC) which may reveal
anemia (if so, ? physiologic)
- Mild peripheral eosinophilia
- Coagulation profile
• Plain radiographs of the abdomen
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COW’S MILK PROTEIN
ALLERGY
Treatment?
Dietary Change is the Key!
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COW’S MILK PROTEIN
ALLERGY
Treatment in the breast fed infant
- Mother must eliminate all dairy
from her diet….
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COW’S MILK PROTEIN
ALLERGY
So what can the breast feeding
mother eat?
- Fresh meats
- Fresh vegetables
- Fresh fruits
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COW’S MILK PROTEIN
ALLERGY
Treatment in the formula fed infant
- Casein hydrolysate formulas
- Elemental (Amino Acid) based
formulas
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COW’S MILK PROTEIN
ALLERGY
Casein hydrolysate formulas
- Alimentum (Abbott)
- Nutramigen (Mead Johnson)
- Pregestimil (Mead Johnson)
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COW’S MILK PROTEIN
ALLERGY
Elemental (Amino Acid) based
formulas
- EleCare (Abbott)
- Neocate (SHS)
- PurAmino (Mead Johnson)
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WHAT ABOUT RECTAL BLEEDING IN
THE PREMATURE INFANT?
• They can also develop Cow’s
Milk Protein Allergy!
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THE DIFFERENTIAL DIAGNOSIS?
• Swallowed maternal blood
• Dietary protein intolerance/allergy
• NEC
• Infectious colitis
• Hirschsprung’s disease with enterocolitis
• Duplication cyst
• Vascular malformations
• Hemophilia
• Maternal Idiopathic Thrombocytopenic Purpura
• Maternal NSAID use
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COW’S MILK PROTEIN
ALLERGY
What’s the natural history?
- Most resolve by 9 mo of age, but
22% can still be intolerant at age 6
years
When can regular formula be
reintroduced?
- 9 months of age
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COW’S MILK PROTEIN
ALLERGY
Is it lactose intolerance?
-NO!
Is it a life long allergy?
-NO!
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COW’S MILK PROTEIN
ALLERGY
Is it Eosinophilic Esophagitis
(EoE)?
-NO!
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4
WHAT ABOUT FPIES ?
• Most commonly less than 3 months of age
• Like CMPA, due to allergic reaction to cow’s milk or soy protein
• Symptoms: diarrhea, nausea, projectile vomiting, dehydration
• Hospitalization is not uncommon
• Often confused with Viral Gastroenteritis
• Symptoms occur 1-3 hours after ingestion (non-IgE)
• Food protein elimination leads to resolution of symptoms in less
than 72 hours
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WHAT ABOUT SOY - BASED
FORMULA?
• If the CMPA is IgE-mediated, soy
protein is usually tolerated
• If the CMPA is non-IgE-mediated,
soy protein is frequently not
tolerated
- In infant GI syndromes, >50% react
to soy in most studies
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HOW IS IT DIFFERENT/SIMILAR
TO EOE?
• Differences
- Location within GI tract
- Dysphagia (EoE) vs Bleeding (CMPA)
- Age of presentation
• CMPA usually younger
• EoE usually older
• Similarities
- Allergic reaction
- Both are due to exposure to an allergen over time
- Both show eosinophilic infiltration on biopsy
• Treatment for both….
- Removal of the Allergen!
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EOSINOPHILIC-ASSOCIATED
GASTROINTESTINAL DISORDERS
Eosinophilic Enteropathy4
• Eosinophils are present throughout the
GI tract – but NOT the esophagus.
• Characterized by increased numbers of
eosinophils within the GI tract mucosa.
• An example of Mixed Mediation Allergy.
• The most common form is Eosinophilic
Esophagitis (EoE)
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EOSINOPHILIC ESOPHAGITIS
• Seen in all ages.
• Similar presentation to GERD
• 2/3 have a personal or family history of
asthma, eczema or allergic rhinitis.
• Diagnosis is by endoscopy with
esophageal biopsy.
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EOSINOPHILIC ESOPHAGITIS
• Infiltration of Eosinophils within the
esophageal mucosa.
• GERD refractory to medical
therapy.
• Greater than 65% of cases appear
in childhood.5
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EOSINOPHILIC ESOPHAGITIS
Symptoms6
Infants
• Feeding refusal
• Failure to thrive
• Regurgitation
• Vomiting
Children
• Dysphagia
• Vomiting
• Abdominal pain
• Heartburn
Adolescents/Adults
• Dysphagia
• Food impaction
• Heartburn
• Reflux
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EOSINOPHILIC ESOPHAGITIS
Diagnosis
• There must be biopsies!
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EOSINOPHILIC ESOPHAGITIS
Diagnosis
• The First International Gastrointestinal
Eosinophilic Research Symposium
(FIGERS) diagnostic guidelines.7
- Eosinophil count of  15/HPF, along with
normal gastric/duodenal biopsies.
- Biopsies after 6 – 8 wk of twice daily acid
suppression with PPI or have a negative
pH probe result.
- Biopsies obtained from  5 esophageal
sites.
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EOSINOPHILIC ESOPHAGITIS
Pathogenesis4
• Driven by Th2 cytokine pathways.
• IL-5 and IL-13 are important mediators of
the EoE inflammatory pathway.
• IgE can be detected on the surface of most
cells and likely contributes to most cell
activation.
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EOSINOPHILIC ESOPHAGITIS
Grossly
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EOSINOPHILIC ESOPHAGITIS
Management
Two components
• Nutritional Management
• Pharmacologic Management
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EOSINOPHILIC ESOPHAGITIS
Management
Nutritional
Management
6 Food Elimination
Milk
Eggs
Nut/Tree nuts
Fish/Shellfish
Wheat
Corn
Amino-Acid Based Diet
Elemental Formulas as a “milk”
source
Allergy testing?
Adapted from Reference 8
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EOSINOPHILIC ESOPHAGITIS
Management-Nutritional
So, when should the eliminated
food be re-introduced and how?
• If you ask 5 gastroenterologists, you might
get 5 different answers.
• There is no consensus statement...YET.
• Once symptoms are resolved, I
reintroduce one eliminated food no faster
than every 2–3 months – Remember,
delayed hypersensitivity!
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EOSINOPHILIC ESOPHAGITIS
Management-Pharmacologic
Pharmacologic
Steroids
Topical vs. Systemic
Adapted from Reference 10
Proton Pump
Inhibitors
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EOSINOPHILIC ESOPHAGITIS
Management-Pharmacologic
• PPIs
- Eliminate GERD symptoms.5
- Not effective alone for EoE.5
- Duration of use?
• Topical Steroids
- Effective in inducing remission.8
- Duration of use?
- Symptoms can recur after withdrawal.9
• Systemic steroids
- Effective in inducing remission.5
- Only for severe or refractory cases.8
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EOSINOPHILIC ESOPHAGITIS
Strictures
What if a stricture is found?
Pharmacologic
and/or dietary
therapy should be
attempted prior to
esophageal dilation.6
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EOSINOPHILIC ESOPHAGITIS
When to refer?
• In any patient with dyspepsia, failure
to thrive or feeding refusal who fails to
respond to “typical” GERD therapy.
• In any patient with persistent
dysphagia/food impactions.
• Consider referral to your allergy
colleagues.
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EOSINOPHILIC ESOPHAGITIS
The Role of Allergy Testing?
Cincinnati vs. Philadelphia
Same research study….different conclusions!
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HOW SHOULD WE ASCEND THE
PRODUCTS PYRAMID?
Elemental
Formulas
Casein
Hydrolysate
Formulas
Intact Protein Formulas
• Blood/mucus in stool
• Atopic dermatitis
• Eosinophilic
Gastroenteropathies
• Short Bowel Syndrome
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HOW SHOULD WE ASCEND THE
PRODUCTS PYRAMID?
Elemental
Formulas
• Continued blood/mucus in stool x 4 wks
• Improved but continued other
signs/symptoms of milk protein allergy
• Eosinophilic Esophagitis*
• Short Bowel Syndrome*
Casein
Hydrolysate
Formulas
Intact Protein Formulas
• Blood/mucus in stool
• Atopic dermatitis
• Eosinophilic
Gastroenteropathies
• Short Bowel Syndrome
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OVERVIEW
• Adverse Food Reactions
- Food Intolerance
- Food Allergy
- Dietary Management is the key
• Cow’s Milk Protein Allergy
- Dietary Management is the key
•
Food Protein-Induced Enterocolitis
- Dietary Management is the key
• Eosinophilic Esophagitis
- Pharmacologic Management
- Dietary Management is the key
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OVERVIEW
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Thank You!
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REFERENCES
1.
Cianferoni A, Speigel JM. Food Allergy: Review, Classification and Diagnosis. Allergology International. 2009;58(4):1-10.
2.
Sicherer SH, et al. Hypoallergenicity and efficacy of an amino acid-based formula in children with cow’s milk and multiple
food hypersensitivities. J Pediatr. 2001;128(5):688-693.
3.
Host A. Frequency of cow’s milk allergy in childhood. Ann Allergy Immunol. 2002;89(6 Suppl 1):33-37
4.
Mansueto, et al. Food Allergy in gastroenterologic diseases: Review of Literature. World J Gastroetnerol,
2006;12(48):7744-7752.
5.
DeBrosse CW, Rothenberg ME. Allergy and Eosinophil-associated Gastrointestinal Disorders (EGID). Curr Opin
Immunol. 2008;20(6):703-708.
6.
Lucendo, et al. Eosinophilic Esophagitis: Current aspects of a recently recognized disease. Gastroenterol Res.
2010;3(2):52-64.
7.
Furutua GT, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations
for diagnosis and treatment. Gastroenterology. 2007;133(4):1342-1363.
8.
Guple AR, et al. Eosinophilic esophagitis. Word J Gastroenterol. 2009;15(1):17-24.
9.
Liacuras CA, et al. Eosinophilic esophagitis: updated consensus recommendation for children and adults. J Allergy Clin
Immunol. 2011;128(1):3-20.
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