Download Cows milk allergy

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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