Food Protein-Induced Enterocolitis Syndrome (FPIES): Review of Recent Guidelines

L'allergie aux protéines du lait de vache chez les nourrissons et les enfants

L'allergie aux protéines du lait de vache (APLV) est une réaction à médiation immunitaire aux protéines du lait de vache, qui peut toucher de multiples systèmes organiques, y compris le tractus gastro-intestinal. Une réaction induite par les immunoglobulines E (IgE) entraîne l'apparition rapide de symptômes allergiques faciles à reconnaître. Cependant, des réactions tardives (non induites par les IgE ou les cellules) ou mixtes (induites par les IgE et les cellules) entraînent une série de symptômes qui ressemblent à d'autres affections et dont le moment d'apparition et la gravité sont très variables. Il est difficile de déterminer si les symptômes sont attribuables à une APLV à médiation immunitaire, à une réaction non immunologique au lait de vache ou à autre chose que l'exposition au lait de vache, mais il est essentiel d'y parvenir pour proposer une prise en charge efficace. Le tableau clinique de l'APLV non induite par les IgE peut varier, mais cette affection, généralement autorésolutive, disparaît entre l'âge de un et six ans. Il faut éviter les batteries de dosages des immunoglobulines G (IgG) pour déceler les intolérances alimentaires spécifiques aux antigènes qui ne reposent pas sur des données probantes, parce qu'elles peuvent entraîner un surdiagnostic de prétendues intolérances alimentaires. Le surdiagnostic d'APLV peut être responsable de la surutilisation de préparations fortement hydrolysées, ce qui a des répercussions financières importantes pour les familles. Le présent document de principes, qui traite de l'APLV non induite par les IgE ou les cellules, aide les professionnels de la santé à distinguer et reconnaître les diverses réactions au lait de vache, aborde le rôle des tests diagnostiques et fournit des recommandations de prise en charge en fonction des données probantes exemplaires.

Cow's milk protein allergy in infants and children

Cow's milk protein allergy (CMPA) is an immune-mediated reaction to cow's milk proteins, which can involve multiple organ systems including the gastrointestinal tract. Immunoglobulin E (IgE)-mediated response results in rapid onset of allergic symptoms that are easily recognizable. However, delayed (i.e., non-IgE/cell-mediated) or mixed (IgE- and cell-mediated) reactions produce a host of symptoms that overlap with other conditions and vary widely in onset and severity. Determining whether symptoms represent immune-mediated CMPA, non-immunologic reaction to cow's milk, or are unrelated to cow's milk exposure is challenging yet essential for effective management. While the clinical presentation of non-IgE-mediated CMPA can vary, this condition is usually self-limited and resolves by 1 to 6 years of age. Food antigen-specific immunoglobulin G (IgG) panels that are not evidence-based should be avoided because they can lead to overdiagnosis of presumed food intolerances. Overdiagnosis of CMPA can result in overuse of extensively hydrolyzed formulas and have significant cost implications for families. This statement focuses on delayed non-IgE/cell-mediated CMPA and assists health care providers to distinguish between and identify varied reactions to cow's milk, discusses the role of diagnostic testing, and provides management recommendations based on best evidence.

Association Between Platelet-to-Lymphocyte Ratio and Preterm Necrotizing Enterocolitis

Introduction: Necrotizing enterocolitis (NEC) is a fatal condition for very-low-birth-weight infants. Necrotizing enterocolitis is a multi-factor phenomenon that results in intestinal mucosal damage and leads to intestinal necrosis. However, sensitive laboratory indicators for NEC are lacking, making early diagnosis difficult. This study aimed to explore the relationship between the platelet-to-lymphocyte ratio (PLR) and NEC in preterm neonates to enable an earlier diagnosis of the condition. Methods: This was a retrospective case-control study of preterm neonates diagnosed with NEC between January 2018 and December 2019 in the West China Second University Hospital. Controls were selected from preterm neonatal intensive care unit (NICU) graduates, and they were matched for gestation and year of birth to the preterms diagnosed without NEC. In total, 93 and 107 infants were included in the NEC and control groups, respectively. Empowerstats analysis was used to identify the association between PLR and preterm NEC. Results: The NEC group had significantly higher PLR levels than the control group. PLR > 100 within 1 week before NEC diagnosis was a risk factor for NEC. There was a positive connection between PLR and preterm NEC. A PLR of >100 was determined as the optimal cutoff for predicting preterm NEC, with patients with PLR >100 having a higher risk of NEC [odds ratio (OR): 18.82 (95% confidence interval (CI): 2.93-120.98), p = 0.002]. Conclusions: A PLR of >100 within 1 week after clinical abnormalities is associated with a high risk of NEC in preterm neonates.

Interdisciplinary Significance of Food-Related Adverse Reactions in Adulthood

Background: Adults frequently interpret food-associated adverse reactions as indicators of a food allergy. However, the public perception of food allergy may differ from a clinician's point of view. The prevalence of patient-reported food allergy tends to be higher than physician-confirmed cases. Dermatological manifestations (urticaria, pruritus, dermatitis, and edema) are frequently reported by patients. Objective: The aim of this study was to describe patient-reported symptoms related to suspected food allergies and particularly to characterize and highlight the volume of patients who visit Budapest allergy clinics with suspected food allergies. Methods: In this prospective study, adult (≥18 years) patients were examined at the Allergology Outpatient Unit of the Dept. of Dermatology, Venereology, and Dermatooncology, Semmelweis University, Budapest. The examination included a detailed medical history; physical examination; and when necessary the measurement of allergen-specific serum immunoglobulin E (IgE) levels. Results: Data from 501 patients (393 women, 108 men) were analyzed. Intolerance to dietary biogenic amines occurred in 250 cases (250/501, 50%). Oral allergy syndrome was confirmed in 71 patients (71/501, 14%). Allergy to food preservatives was diagnosed in 14 (14/501, 3%) cases by a dermatologist-allergist specialist. Five individuals (5/501, 1%) were diagnosed with IgE-mediated food allergy. In some cases (28/501, 6%), edema-inducing/enhancing side effects of drugs were observed which patients had misattributed to various foods. Among the food groups considered to be provoking factors, the most frequently mentioned were fruits (198/501, 40%), milk/dairy products (174/501, 35%), and nuts/oilseeds (144/501, 29%). Overwhelmingly, urticaria (47%) was the most common dermatological diagnosis, followed by dermatitis (20%) and allergic contact dermatitis (8%). Conclusion: Improvement is needed in food allergy, food intolerance, and general nutritional knowledge among the general public. According to our data, perceived/self-reported food allergies were overestimated by adults when compared against physician-confirmed food allergies; however, other diseases potentially responsible for food-related problems were underestimated. The prevalence of oral allergy syndrome was high in the cohort. Intolerance to dietary biogenic amines was common, and although the role of dietary histamine and biogenic amine is not entirely understood in eliciting patients' symptoms, improvements in complaints were reported during the control visits.

FPIES in exclusively breastfed infants: two case reports and review of the literature

Background

Food Protein-Induced Enterocolitis Syndrome (FPIES) is a non IgE-mediated food allergy that generally affects children in the first year of life. Usually symptoms break out when formula milk or solid foods are introduced for the first time but they might also appear in exclusively breastfed infants, since the trigger elements, especially cow’s milk proteins, can be conveyed by maternal milk as well. FPIES in exclusively breastfed babies is a very rare clinical condition and only few cases have been reported in the medical literature.

Case presentation

We describe two cases of FPIES in exclusively breastfed babies. The first one is a two-month-old infant with a brief history of vomit and diarrhea that presented to the Emergency Department in septic-like conditions. The main laboratory finding was a significant increase in methemoglobin (13%). Clinically, we noted that, when breastfeeding was suspended, diarrhea drastically improved, and vice versa when maternal milk was reintroduced. An amino acid-based formula allowed a complete normalization of the symptoms. The second one is a three-month-old infant admitted for a 3 days history of persistent vomit and diarrhea. Blood tests showed a raised level of methemoglobin (7%). An esophagogastroduodenoscopy was performed and biopsies showed an eosinophilic infiltration of the duodenal mucosa. A maternal exclusion diet and an amino acid-based formula allowed a rapid regularization of the bowel function.

Conclusions

We searched all the cases of FPIES in exclusively breastfed babies reported in the medical literature, identifying eight patients, with an average age of 3 months (range 15 days – 6 months). The majority of the cases were initially diagnosed as gastroenteritis or sepsis, five cases were characterized by an acute on chronic scenario and cow’s milk was the most frequently involved food. Methemoglobin was never tested. An oral food challenge test was performed in two patients.

FPIES in exclusively breastfed infants is a rare condition that, in the presence of compatible history and symptoms, should be considered also in exclusively breastfed babies. The evaluation of methemoglobin can simplify the diagnostic process.

Mechanisms of gastrointestinal allergic disorders

Gastrointestinal (GI) allergic disease is an umbrella term used to describe a variety of adverse, food antigen-driven, immune-mediated diseases. Although these diseases vary mechanistically, common elements include a breakdown of immunologic tolerance, a biased type 2 immune response, and an impaired mucosal barrier. These pathways are influenced by diverse factors such as diet, infections, exposure to antibiotics and chemicals, GI microbiome composition, and genetic and epigenetic elements. Early childhood has emerged as a critical period when these factors have a dramatic impact on shaping the immune system and therefore triggering or protecting against the onset of GI allergic diseases. In this Review, we will discuss the latest findings on the molecular and cellular mechanisms that govern GI allergic diseases and how these findings have set the stage for emerging preventative and treatment strategies.

Recent developments and highlights in biomarkers in allergic diseases and asthma

The potential of precision medicine in allergy and asthma has only started to be explored. A significant clarification in the pathophysiology of rhinitis, chronic rhinosinusitis, asthma, food allergy and drug hypersensitivity was made in the last decade. This improved understanding led to a better classification of the distinct phenotypes and to the discovery of new drugs such as biologicals, targeting phenotype-specific mechanisms. Nevertheless, many conditions remain poorly understood such as non-eosinophilic airway diseases or non-IgE-mediated food allergy. Moreover, there is a need to predict the response to specific therapies and the outcome of drug and food provocations. The identification of patients at risk of progression towards severity is also an unmet need in order to establish adequate preventive or therapeutic measures. The implementation of precision medicine in the clinical practice requires the identification of phenotype-specific markers measurable in biological matrices. To become useful, these biomarkers need to be quantifiable by reliable systems, and in samples obtained in an easy, rapid and cost-efficient way. In the last years, significant research resources have been put in the identification of valid biomarkers for asthma and allergic diseases. This review summarizes these recent advances with focus on the biomarkers with higher clinical applicability.