Cow's milk protein intolerance and chronic constipation in children

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.

Myths and misconceptions about childhood constipation

Many widely held beliefs and assumptions concerning childhood constipation continue to interfere with rational management of childhood constipation. Although many still believe that constipation is not a common disease, about 9.5% of the world's children suffer from chronic constipation. Most of these children live in non-Western countries. There are major misconceptions about the etiology of constipation as a significant proportion of clinicians still believe that constipation is caused by some form an organic pathology, whereas in reality, the majority have functional constipation. Contrary to a commonly held belief that children outgrow constipation without long-term problems, there is evidence that constipation leads to significant bowel and psychological consequences and has a major impact on the quality of life which detrimentally affects future health and education. Finally, ineffective management strategies such as increasing fiber and water in the diet, and short duration of treatment owing to the fear that long-term laxative treatment leads to colonic dysfunction, interfere with effective therapeutic strategies.   Conclusions: It is apparent that myths and misconception often lead to wrong assumptions regarding the distribution of the disease, its etiology, pathophysiology, and management leading to ordering incorrect investigations and ineffective therapeutic strategies while spending large sums of public funds unnecessarily. Poorly treated constipation leads to deleterious psychological consequences predisposing children to develop significant psychological damage and bowel dysfunctions. This review aims to challenge these myths about various elements of constipation by exploring the existing literature and encouraging clinicians to have a fresh look at old concepts that could interfere with the well-being of children with constipation. What is Known: • Childhood constipation is a growing problem in the world leading to significant suffering and high healthcare expenditure • Myths and misconceptions lead to poor management strategies causing psychological and bowel damage What is New: • Organic, systemic, and bowel disorders leading to constipation are uncommon, and in the majority, it arises due to deliberate fecal withholding and most investigations ordered by clinicians are not very helpful in the management • Most non-pharmacological interventions are not effective in the day-to-day management of childhood constipation. The use of laxatives is considered to be the first-line management strategy.

Childhood constipation: Current status, challenges, and future perspectives

Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.

Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

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.

Associations between dairy consumption and constipation in adults: A cross-sectional study

OBJECTIVE

The current study aimed to assess the association between dairy consumption and constipation in the general adult population.

DESIGN

Data from the Geelong Osteoporosis Study were used to assess the association between dairy consumption and constipation in women (n=632) and men (n=609). Information on milk, yogurt and cheese, and constipation were self-reported. Total dairy was calculated by summing the intake of milk, yogurt and cheese and expressed as servings per day. Multivariable logistic regression models adjusted for irritable bowel syndrome, major depressive disorders, mobility, body mass index, age and fibre intake were used to examine the odds ratio (OR) and 95% confidence interval (CI) between the consumption of categories of total dairy, milk, yogurt, cheese, and constipation.

RESULTS

In women, consumption of 1-2 servings/d of total dairy was associated with reduced odds for constipation (OR: 0.49; 95% CI: 0.26-0.90; P=0.021) compared to consuming <1 serving/d of total dairy after adjusting for covariates. Also, consumption of 1-4 servings/d of milk was associated with marginally reduced odds for constipation (OR: 0.63; 95% CI: 0.39-1.02; P=0.058) compared to women who consumed <1 serving/d of milk after adjusting for covariates. There were no significant associations detected between other types of dairy consumption and constipation in women, and none in men.

CONCLUSION

In women, consumption of moderate amounts of dairy is associated with reduced odds for constipation whereas in men no associations were detected between dairy consumption and constipation. Further studies are warranted to confirm results.

An updated overview of spectrum of gluten-related disorders: clinical and diagnostic aspects

The incidence of gluten-related disorders (GRDs) continues to increase and its global prevalence is estimated at approximately 5% of the population. Celiac disease (CD), dermatitis herpetiformis (DH), gluten ataxia (GA), wheat allergy (WA), and non-celiac gluten sensitivity (NCGS) are the five major GRDs that present with a wide range of clinical manifestations. The diagnosis of GRDs can be challenging because the typical and atypical clinical manifestations of the GRDs overlap. In this review, the current definitions of gluten-related disorders, focusing on their clinical features, diagnostic and therapeutic approaches are presented. We concluded that GRDs are usually diagnosed using a combination of clinical features, serological tests, and histopathological findings. Treatment usually involves dietary modification.

Cow's Milk Protein Allergy in Infancy: A Risk Factor for Functional Gastrointestinal Disorders in Children?

The role and prevalence of cow's milk protein allergy (CMA) in functional gastrointestinal disorders remains unclear. The aim of this review is to update knowledge on the relationship between CMA and functional abdominal pain disorders (FAPDs) in children. Cochrane Database and Pubmed were searched from inception using general and specific terms for CMA and functional gastrointestinal disorders. CMA is reported as a predisposing or coexisting factor in a wide range of functional gastrointestinal disorders in infants and children. Pathogenesis of both conditions is complex and multiple mechanisms including dysmotility and hypersensitivity might contribute to the clinical manifestations. Data supporting the possible role of food allergies in the pathogenesis of FAPDs are limited. CMA may predispose to early life inflammation and visceral hypersensitivity, which in turn might manifest as FAPDs. The diagnosis of either CMA or FAPDs and distinction between them is challenging because of nonspecific and overlapping symptoms. Lack of accurate allergy tests in non-IgE (immunoglobulin E) mediated cases is also problematic. Oral food challenge, following an elimination diet, should be performed to diagnose a suspected non-IgE CMA allergy in children with FAPDs. In the management of FAPDs, an elimination diet should be considered for a limited period to verify if the symptoms improve or resolve.

Laxative Choice and Treatment Outcomes in Childhood Constipation: Clinical Data in a Longitudinal Retrospective Study

PURPOSE

Functional constipation (FC) is a common gastrointestinal (GI) problem affecting children's well-being and quality of life. Although polyethylene glycol (PEG) is recommended as the first line therapy, it is not always applicable in lower socioeconomic populations. Hence, this study aimed to compare clinical courses of FC in children treated with different medications in order to identify prognostic factors related to treatment outcomes.

METHODS

We reviewed the medical records of patients aged ≤15 years diagnosed with FC according to the Rome IV criteria from 2007 to 2015 at the GI clinic, Songklanagarind Hospital. Baseline characteristic, medical history, and treatment outcomes were collected at first and subsequent visits.

RESULTS

Exactly 104 patients (median age at diagnosis, 2.8 years) were diagnosed with FC. The number of follow-up visits per patient ranged from 1 to 35. The median duration of follow-up was 18.0 months (range, 6.0-84.2 months). PEG was given to 21% of patients. During the follow up period, 76% of patients experienced first recovery with a median time to recovery of 9.8 months. There were no significant differences in time until first recovery and relapse between patients who received and those who did not receive PEG (p=0.99 and 0.06, respectively). Age >6 years, normal defecation frequency, no history of cow's milk protein allergy, and use of laxatives were associated with successful outcomes.

CONCLUSION

Treatment outcomes between patients who had and never had PEG demonstrated no significant difference in our study. Hence, current practices in laxative prescriptive patterns may be effective.

Non-IgE-mediated gastrointestinal food allergies in children

Non-IgE-mediated gastrointestinal food allergic disorders (non-IgE-GI-FA) including food protein-induced enterocolitis syndrome (FPIES), food protein-induced enteropathy (FPE), and food protein-induced allergic proctocolitis (FPIAP) are relatively uncommon in infants and young children, but are likely under-diagnosed. Non-IgE-GI-FA have a favorable prognosis, with majority resolving by age 3-5 years. Diagnosis relies on the recognition of symptoms pattern in FPIAP and FPIES and biopsy in FPE. Further studies are needed for a better understanding of the pathomechanism, which will lead eventually to the development of diagnostic tests and treatments. Limited evidence supports the role of food allergens in subsets of constipation, gastroesophageal reflux disease, irritable bowel syndrome, and colic. The immunologic pathomechanism is not fully understood and empiric prolonged avoidance of food allergens should be limited to minimize nutrient deficiency and feeding disorders/food aversions in infants.

Are Diet and Constipation Related in Children?

Constipation is a common complaint in childhood, and the etiology of many healthcare referrals. Despite literature documenting the high frequency of this problem, there is little research directly relating the food consumed and the eventual stool consistency. There is literature suggesting the importance of adequate fiber intake in children to maintain soft stools. Other dietary modifications actually have not been shown to be helpful or are not based on actual clinical studies. The presence of dietary allergies may also contribute to etiology of constipation. More studies to provide further linkages between diet and constipation are clearly needed.

Evaluation of an online “teachable moment” dietary intervention

Purpose

The purpose of this paper is to evaluate an online “teachable moment” intervention to promote healthy eating for overweight and food intolerance symptoms.

Design/methodology/approach

The study involves a 2×2 factorial design with two conditions: group (weight loss vs food intolerance) and condition (intervention vs control). The intervention aimed to generate a “teachable moment” by providing knowledge regarding the relationship between food and the problem (overweight or food intolerance), focussing on the negative aspects of the problem, creating a behavioural model, and encouraging hope and reinvention. Participants receiving the intervention (n=22) completed measures of dietary behaviour and either weight or food intolerance symptoms before receiving the intervention and again one month later. Control participants (n=20) provided measures but did not receive the intervention.

Findings

There were no significant reductions in weight or food intolerance symptoms. However, compared to control participants, participants in the intervention conditions reported greater intentions to eat healthily (p=0.01) and improved healthy eating behaviour over time, following both an intention-to-treat (p=0.046) and explanatory analysis (p=0.042).

Practical implications

Encouraging individuals to perceive their everyday situation as a time for change and adopt healthier behaviour early on, may prevent future diet-related medical events. This has benefits for both the individual and for health care costs.

Originality/value

A quick and easy-to-administer online “teachable moment” intervention improves dietary behaviour and can be minimally adapted to suit individuals with differing health needs.

Cow's Milk Protein Allergy

Cow's milk protein allergy (CMPA) is a common condition encountered in children with incidence estimated as 2% to 7.5% in the first year of life. Formula and breast-fed babies can present with symptoms of CMPA. It is important to accurately diagnose CMPA to avoid the consequences of either under- or overdiagnosis. CMPA is classically categorized into immunoglobulin E (IgE)- or non-IgE-mediated reaction that vary in clinical manifestations, diagnostic evaluation, and prognosis. The most commonly involved systems in patients with CMPA are gastrointestinal, skin, and respiratory. Evaluation of CMPA starts with good data gathering followed by testing if indicated. Treatment is simply by avoidance of cow's milk protein (CMP) in the child's or mother's diet, if exclusively breast-feeding. This article reviews the definition, epidemiology, risk factors, pathogenesis, clinical presentation, evaluation, management, and prognosis of CMPA and provides an overview of different options for formulas and their indication in the treatment of CMPA.

Effects of milk containing only A2 beta casein versus milk containing both A1 and A2 beta casein proteins on gastrointestinal physiology, symptoms of discomfort, and cognitive behavior of people with self-reported intolerance to traditional cows' milk

Background

Cows’ milk generally contains two types of β-casein, A1 and A2 types. Digestion of A1 type can yield the peptide β-casomorphin-7, which is implicated in adverse gastrointestinal effects of milk consumption, some of which resemble those in lactose intolerance. This study aimed to compare the effects of milk containing A1 β-casein with those of milk containing only A2 β-casein on inflammation, symptoms of post-dairy digestive discomfort (PD3), and cognitive processing in subjects with self-reported lactose intolerance.

Methods

Forty-five Han Chinese subjects participated in this double-blind, randomized, 2 × 2 crossover trial and consumed milk containing both β-casein types or milk containing only A2 β-casein. Each treatment period was 14 days with a 14-day washout period at baseline and between treatment periods. Outcomes included PD3, gastrointestinal function (measured by smart pill), Subtle Cognitive Impairment Test (SCIT), serum/fecal laboratory biomarkers, and adverse events.

Results

Compared with milk containing only A2 β-casein, the consumption of milk containing both β-casein types was associated with significantly greater PD3 symptoms; higher concentrations of inflammation-related biomarkers and β-casomorphin-7; longer gastrointestinal transit times and lower levels of short-chain fatty acids; and increased response time and error rate on the SCIT. Consumption of milk containing both β-casein types was associated with worsening of PD3 symptoms relative to baseline in lactose tolerant and lactose intolerant subjects. Consumption of milk containing only A2 β-casein did not aggravate PD3 symptoms relative to baseline (i.e., after washout of dairy products) in lactose tolerant and intolerant subjects.

Conclusions

Consumption of milk containing A1 β-casein was associated with increased gastrointestinal inflammation, worsening of PD3 symptoms, delayed transit, and decreased cognitive processing speed and accuracy. Because elimination of A1 β-casein attenuated these effects, some symptoms of lactose intolerance may stem from inflammation it triggers, and can be avoided by consuming milk containing only the A2 type of beta casein.

Trial registration

ClinicalTrials.gov/NCT02406469

Electronic supplementary material

The online version of this article (doi:10.1186/s12937-016-0147-z) contains supplementary material, which is available to authorized users.

Early-life factors associated with pediatric functional constipation

OBJECTIVE

This multicenter prospective study aimed to establish possible risk factors for functional constipation (FC) in the first year of life.

METHODS

At the infant's age of 3, 6, and 12 months, parents of all included infants completed 2 questionnaires: one about the presence of FC and the other screened the possible risk factors for FC. Parents of 465 infants completed the questionnaires at 3 and 6 months and of 402 infants at 12 months of life.

RESULTS

According to the Rome III criteria, FC was found in 11.6% of the infants at 3 months, in 13.7% at 6 months, and in 10.7% at 12 months after birth. Family history of atopy was present in 38.8% and 45.3% of infants with constipation at 3 and 6 months (P = 0.04 and P = 0.02, respectively), but no significant association was found at 12 months (P = 0.80). Breast-feeding was significantly related to a normal evacuation pattern at 3 months (P = 0.05), but not at 6 and 12 months (P = 0.12 and P = 0.9, respectively). Acetaminophen and female sex appeared to be risk factors for FC at 12 months. After the adjustment for all analyzed variables, FC in infants was significantly associated with the use of acetaminophen (odds ratio 6.98, 95% confidence interval 0.82-13.50).

CONCLUSIONS

Our results confirmed that breast-feeding is a protective factor for FC in the first 3 months of life and that the female sex is at risk to have FC. We found that the use of acetaminophen was associated with a higher incidence of FC in the first year of life.

Food allergy-related paediatric constipation: the usefulness of atopy patch test

The aims of this study were to evaluate the implication of food allergy as a cause of paediatric constipation and to determine the diet period needed to tolerate the constipation-causing foods. Fifty-four children aged 6 months to 14 years (median, 42 months) suffering from chronic constipation (without anatomic abnormalities, cοeliac disease or hypothyroidism), unresponsive to a 3-month laxative therapy, were prospectively evaluated. All participants were evaluated for allergy to cow's milk, egg, wheat, rice, corn, potato, chicken, beef and soy, using skin tests (SPT), serum specific IgE and atopy patch test (APT). A withdrawal of the APT-positive foods was instructed. Thirty-two children had positive APT; 15 were positive to one; six, to two and 11, to three or more food allergens, wheat and egg being the commonest. After withdrawing the APT-positive foods for an 8-week period, constipation had improved in 28/32 children, but a relapse of constipation was noticed after an oral food challenge, so they continued the elimination diet. Tolerance to food allergens was achieved in only 6/28 after 6 months, compared to 25/28 after 12 months and to all after a 2-year-long elimination. Food allergy seems to be a significant etiologic factor for chronic constipation not responding to treatment, in infants and young children. APT was found to be useful in evaluating non-IgE allergy-mediated constipation, and there was no correlation of APT with IgE detection. Tolerance was adequately achieved after 12 months of strict food allergen elimination.

Nuclear transit studies of patients with intractable chronic constipation reveal a subgroup with rapid proximal colonic transit

AIMS/BACKGROUND

Nuclear transit studies (NTS) allow us to follow transit through the stomach and the small and large intestines. We identified children with chronic constipation with rapid proximal colonic transit and characterized their clinical features.

METHODS

We reviewed NTS from 1998 to 2009 to identify patients with chronic constipation and rapid proximal colonic transit, defined as greater than 25% of tracer beyond hepatic flexure at 6 hour and/or greater than 25% of tracer beyond end of descending colon at 24 hour. This was correlated with clinical symptoms and outcome from patient records.

RESULTS

Five hundred twenty children with chronic constipation underwent investigation by NTS, and 64 (12%) were identified with rapid proximal colonic transit. The clinical history, symptoms, and outcome in 55 of 64 available for analysis frequently showed family history of allergy (10.9%) and symptoms associated with food allergy/intolerance: abdominal pain (80%), anal fissure (27.3%), and other allergic symptoms (43.6%). Eighteen children were treated with dietary exclusion, with resolution of symptoms in 9 (50%).

CONCLUSIONS

Some children with intractable chronic constipation have rapid proximal colonic transit, have symptoms consistent with possible food allergy/intolerance, and may respond to dietary exclusion. The NTS can identify these patients with rapid proximal transit that may be secondary to food intolerance.

Constipation in children: novel insight into epidemiology, pathophysiology and management

Constipation in children is a common health problem affecting 0.7% to 29.6% children across the world. Exact etiology for developing symptoms is not clear in children and the majority is considered to have functional constipation. Alteration of rectal and pelvic floor function through the brain-gut axis seems to play a crucial role in the etiology. The diagnosis is often a symptom-based clinical process. Recently developed Rome III diagnostic criteria looks promising, both in clinical and research fields. Laboratory investigations such as barium enema, colonoscopy, anorectal manometry and colonic transit studies are rarely indicated except in those who do not respond to standard management. Treatment of childhood constipation involves several facets including education and demystification, toilet training, rational use of laxatives for disimpaction and maintenance and regular follow-up. Surgical options should be considered only when medical therapy fails in long standing constipation. Since most of the management strategies of childhood constipation are not evidence-based, high-quality randomized controlled trials are required to assess the efficacy of currently available or newly emerging therapeutic options. Contrary to the common belief that children outgrow constipation as they grow up, a sizable percentage continue to have symptoms beyond puberty.

Cow's-milk-free diet as a therapeutic option in childhood chronic constipation

OBJECTIVES

It has been reported that a number of children with constipation respond to a diet free of cow's-milk (CM) proteins, although evidence is lacking to support an immunoglobulin E-mediated mechanism.

PATIENTS AND METHODS

We performed an open-label crossover study comparing CM and rice milk in 69 children who fulfilled Rome III criteria for chronic constipation. Clinical, physical, and immunologic parameters of patients who responded (R) and who did not respond (NR) to a CM-free diet were compared.

RESULTS

Thirty-five of the 69 children (51%) improved during the first CM-free diet phase, 8 of these did not develop constipation when CM was reintroduced, and 27 children (39%) developed constipation during the CM challenge and improved during the second CM-free diet phase (R group). Thirty-four children (49%) did not improve during the first CM-free diet phase (NR group). Bowel movements per week among R children significantly increased compared with NR children (R: 2.8-7.7 vs NR: 2.6-2.7) (P < 0.001). Seventy-eight percent of the children with developmental delay responded to the CM-free diet (P = 0.007). No significant statistical difference was found between the R and NR children in terms of fiber and milk consumption; atopic or allergic history; full-blood eosinophil count and percentage, and lymphocyte populations; immunoglobulins, immunoglobulin (Ig)G subclasses, total IgE; and serum-specific immunoglobulin E for CM proteins.

CONCLUSIONS

A clear association between CM consumption and constipation has been found in more than one third of children. However, analytical parameters do not demonstrate an immunoglobulin E-mediated immunologic mechanism.

Cow's milk allergy related pediatric constipation: appropriate time of milk tolerance

Cow's milk allergy (CMA) has different clinical presentations according to age. The study aimed to evaluate the extent of CMA as a cause of pediatric constipation and determine the appropriate timing of tolerance to cow milk in such patients. The study included 60 patients suffering from chronic functional constipation, 27 of whom did not respond to 2 month laxative therapy (group I). Thirty age and sex matched apparently healthy infants and children were studied as a control group (group II). Serum specific IgE to cow milk proteins was measured. Withdrawal of cow milk and dairy products for a 1 month period was then followed by cow milk re-challenge over 2 wk. Patients were classified into: responders to this schedule (cow milk allergic=group Ia; n=21) and non-responders (non-cow milk allergic=group Ib; n=6). Eighteen CMA patients continued the study where nine of them underwent milk reinstitution after 6 months and another nine patients after 12 months of elimination. The frequency of CMA among constipated patients was 77.7%. Mean values of serum specific IgE to whole cow milk protein and beta-lactoglobulins were significantly higher in constipated patients (0.82+/-0.08, 0.79+/-0.13 IU/ml, respectively) compared with controls (0.26+/-0.14, 0.27+/-0.14 IU/ml, respectively) and in group Ia (0.99+/-0.08, 0.95+/-0.14 IU/ml, respectively) compared with group Ib (0.39+/-0.06, 0.37+/-0.10 IU/ml, respectively). Serum specific IgE was positive in 85.7% of CMA group, predominantly in class 2. Tolerance to cow milk was achieved after 6 months in only 22.2% compared with 88.8% after 12 months of elimination. In conclusion, CMA is shown to be a significant etiologic factor for constipation in infants and young children. Serum levels of IgE to cow milk proteins are helpful although not definitive for diagnosis. Based on this limited study, tolerance is better achieved after 12 months of strict cow's milk elimination.

Clinical management of motility disorders in children

We review the current clinical evaluation and management of the most common esophageal and gastrointestinal motility disorders in children based on the literature and our experience in a pediatric motility center in the United States. The disorders discussed include esophageal achalasia, pre- and post-fundoplication motility disorders, gastroparesis, motility disorders occurring after repair of congenital atresias, motility disorders associated with gastroschisis, chronic intestinal pseudo-obstruction, motility after intestinal transplantation, motility disorders after colonic resection for Hirschsprung's disease, chronic functional constipation, and motility disorders associated with imperforate anus.

Neuroimmune interaction and anorectal motility in children with food allergy-related chronic constipation

OBJECTIVES

Food allergy is thought to trigger functional constipation in children but the underlying mechanisms are still unknown. Mast cells (MCs) and their relationship with nerve fibers (NFs) in the rectal mucosa, as well as anorectal motility, were studied in children with refractory chronic constipation before and after an elimination diet for cow's milk, egg, and soy proteins.

METHODS

Thirty-three children (range: 1-10.8 years) underwent anorectal manometry and suction rectal biopsy before and after 8 weeks of oligoantigenic diet. MCs and NFs were identified immunohistochemically. Quantification of MCs (%MC/area) and MCs within 10 microm of NFs (%MC-NF/area) was performed by computer-assisted analysis.

RESULTS

Eighteen children responded to the diet (R-group) and fifteen did not (the NR-group). At baseline there was a significant difference in anal resting pressure (ARP; mm Hg), percentage of relaxation (%R), and residual pressure (RP; mm Hg) of anal canal during rectal distension between the R-group (66+/-4.1, 84.3+/-2.8, 10.4+/-2.3, respectively) and the NR-group (49+/-5, 92.2+/-1.7, 4.8+/-1.7, respectively; P<0.05). After the diet, significant changes in ARP, RP, and %R were observed only in the R-group (44+/-3.7, 93.7+/-1.5, 3.8+/-1.2, respectively; P<0.05). At baseline, the R-group showed an increase in %MC/area (8.3+/-0.7) and %MC-NF/area (5.2+/-2.6) with respect to the NR-group (5.1+/-0.5 and 2.3+/-0.4, respectively; P<0.05). After the diet, only the R-group showed a significant reduction of %MC/area and %MC-NF/area (4.4+/-0.5 and 2.2+/-0.4, respectively; P<0.001). Both ARP and RP significantly correlated with %MC/area and %MC-NF/area; %R showed a significant inverse correlation with both %MC/area and %MC-NF/area.

CONCLUSIONS

In children with food allergy-related chronic constipation, an increase in both rectal MC density and spatial interactions between MCs and NFs correlates with anal motor abnormalities. These variables are significantly affected by the diet.

Pediatric anorectal disorders

This article reports the clinical, physiopathologic, diagnostic, and therapeutic aspects of the most common anorectal disorders in children. In particular, it focuses on the differential diagnosis between organic and functional constipation. In addition, the authors separately examine some of the clinical conditions such as atopy, neurologic diseases, and anorectal malformations, in which chronic constipation may be an important clinical manifestation.

Allergic proctitis and abdominal distention mimicking Hirschsprung's disease in infants

AIM

To determine the incidence and clinical aspects of allergic proctitis (AP) in infants with symptoms that mimic Hirschsprung's disease (HD).

METHODS

One hundred and five patients less than 6 months of age, who underwent barium enema, anorectal manometry and rectal suction biopsy due to suspicion of HD, were enrolled. Comparison of the patient characteristics associated with each disease was based on the results of the triple testing. The sensitivity and specificity of the three tests, for the diagnosis of HD, were evaluated.

RESULTS

The mean age of enrolled patients was 2.1+/-0.9 months. Based on the three tests, 39 patients (37.1%) were diagnosed with HD, seven patients (6.7%) with AP, and 53 (50.5%) had normal results. Of the 54 patients with transitional zone and a reversed rectosigmoid index on the barium enema, four (7.4%) were patients with AP. The mean age of the AP patients (3.1+/-1.5 months old) was older than the HD children (1.4+/-0.9 months old). The sensitivity of the three tests for HD was 97.4%, 87.2% and 92.3% and the specificity was: 74.2%, 78.8% and 100%, respectively.

CONCLUSIONS

In the infants with severe abdominal distention, the incidence of AP mimicking HD was relatively high. Therefore, consideration of AP should be part of the differential diagnosis in infants with severe abdominal distention or findings that mimic HD. For differentiation of these disorders, a rectal suction biopsy is very useful.

Darmentleerung, Sauberkeitsentwicklung bei Kindern und ihre Störungen (Obstipation und Enkopresis)

Zusammenfassung. Verstopfung und Stuhlinkontinenz bei Kindern stellen für die Betroffenen und deren Familien eine schwere Belastung dar. In den meisten Fällen liegen funktionelle Störungen ohne organische Erkrankungen zugrunde. Trotzdem muss bei jedem Kind eine zielgerichtete somatische Diagnostik erfolgen. Rein psychische Ursachen für Obstipation und Inkontinenz sind eher selten. Nach Eingrenzen der Diagnose kann durch verschiedene Therapieansätze eine Besserung der Symptomatik erfolgen. Neben medikamentösen und diätetischen Maßnahmen stehen verhaltenstherapeutische Ansätze im Vordergrund. Der vorliegende Text gibt einen Überblick über den aktuellen Stand der wissenschaftlichen Erkenntnisse zu Kontinenzentwicklung, Physiologie und Pathophysiologie der Darmentleerung sowie Diagnostik und Behandlung von Obstipation und Enkopresis aus pädiatrisch-gastroenterologischer Sicht.

Review article: Chronic constipation and food hypersensitivity--an intriguing relationship

BACKGROUND

Chronic constipation is common in the general population. Some studies have shown that in children cow's milk protein hypersensitivity can cause chronic constipation unresponsive to laxative treatment.

AIMS

To review the literature and summarize the data that point to a relationship between refractory chronic constipation and food hypersensitivity, and to discuss the hypothesis that the pathogenesis of constipation due to food hypersensitivity.

METHODS

A search in the U.S. National Library of Medicine was performed, matching the key words 'chronic constipation, food intolerance and allergy'.

RESULTS

Thirty-three papers were found but only 19 of them were related to the topic of this review. Most of the data indicated a relationship between constipation and food allergy in a subgroup of paediatric patients with 'idiopathic' constipation unresponsive to laxative treatment. There was only one study in adults that demonstrated the resolution of chronic constipation on hypoallergenic diet in four patients.

CONCLUSIONS

An increasing number of reports suggest a relationship between refractory chronic constipation and food allergy in children. Similar data in adults are scarce and need to be confirmed. Further studies should be performed to obtain firmer evidence for the role of allergy in constipation and clarify the pathogenetic mechanisms involved.

Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Constipation is a common pediatric problem. To assist health care professionals who care for children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) previously published a clinical guideline based on an integration of medical evidence with expert opinion. To evaluate studies published since then, the NASPGHAN Constipation Guideline Committee performed a comprehensive and systematic review of the medical literature since 1997, to identify, review and rate the quality of new evidence. Based on this review, the recommendations of the original clinical guideline were reaffirmed with several modified according to the new evidence. Below is a summary of the evidence reviewed for this update. The complete revised guideline is available online in its entirety.

Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. The Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has formulated a clinical practice guideline for the management of pediatric constipation. The Constipation Guideline Committee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Guideline Committee also provided recommendations for management by the pediatric gastroenterologist.

Gastroesophageal reflux disease, colic and constipation in infants with food allergy

PURPOSE OF REVIEW

This review assesses the role of food allergy in the pathophysiology of gastroesophageal reflux disease, colic and constipation in infancy.

RECENT FINDINGS

Frequent regurgitation, persistent crying and constipation are common clinical problems in infancy. A subgroup of infants with these conditions may respond to hypoallergenic diets, but only few randomized clinical trials have been conducted. Skin prick testing and food-specific antibody levels are usually not elevated in these infants, whereas atopy patch testing may diagnostic. The mechanisms by which cow's milk and other food allergens induce gastrointestinal motility disorders are not understood. Apart from cell-mediated reactions, non-immunological effects of food constituents on gastrointestinal motility and gut microbiota may be involved in the pathogenesis. In the absence of reliable diagnostic tests, dietary elimination and re-challenge are usually required to confirm food allergy. A trial of amino acid-based formula or an oligoantigenic maternal elimination diet may be indicated in infants who have failed conventional medical treatment.

SUMMARY

Food allergy may contribute to gastroesophageal reflux disease, colic or constipation in infancy. Infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet. Further research is needed to define the mechanisms and clinical markers of gastrointestinal food allergy in infancy.

Food intolerance and chronic constipation: manometry and histology study

BACKGROUND

Chronic constipation in children can be caused by cows' milk intolerance (CMI), but its pathogenesis is unknown.

AIMS

To evaluate the histology and manometry pattern in patients with food intolerance-related constipation.

PATIENTS AND METHODS

Thirty-six consecutive children with chronic constipation were enrolled. All underwent an elimination diet and successive double-blind food challenge. All underwent rectal biopsy and anorectal manometry.

RESULTS

A total of 14 patients were found to be suffering from CMI and three from multiple food intolerance. They had a normal stool frequency on elimination diet, whereas constipation recurred on food challenge. The patients with food intolerance showed a significantly higher frequency of erosions of the mucosa, and the number of intra-epithelial lymphocytes and eosinophils. The rectal mucous gel layer showed that the food-intolerant patients had a significantly lower thickness of mucus than the other subjects studied. Manometry showed a higher anal sphincter resting pressure and a lower critical volume in food intolerance patients than in the others suffering from constipation unrelated to food intolerance. Both histology and manometry abnormalities disappeared on the elimination diet.

CONCLUSIONS

Food intolerance-related constipation is characterized by proctitis. Increased anal resting pressure and a reduced mucous gel layer can be considered to be contributory factors in the pathogenesis of constipation.

Breath hydrogen test after a bean meal demonstrates delayed oro-cecal transit time in children with chronic constipation

OBJECTIVE

To evaluate oro-cecal transit time in children with chronic constipation.

METHODS

34 patients with chronic functional constipation age 3 to 13 years and 15 controls without constipation. Oro-cecal transit time was evaluated using the hydrogen breath test after ingestion of lactulose and after a standard meal of cooked beans. Total and segmental colonic transit times were measured with radiopaque markers.

RESULTS

Of 34 patients with chronic constipation 61.8% had increased total colonic transit time (>62 hours). Oro-cecal transit time measured with lactulose as substrate was similar (p=0.727) in constipated patients with increased colonic transit time (63.8+/-16.3 minutes), in constipated patients with normal colonic transit time (66.9+/-22.9 minutes), and in controls (65.3+/-15.5 minutes). Using a test meal of beans, the hydrogen breath test showed that oro-cecal transit time of constipated patients with increased total colon transit time was higher (252.4+/-23.2 minutes) than oro-cecal transit time of constipated patients with normal colonic transit time (227.7+/-39.6 minutes) or controls (205.3+/-23.3 minutes) (p<.05).

CONCLUSION

Hydrogen excretion in breath after a bean test meal showed delayed oro-cecal transit time in children with chronic constipation with abnormal total colonic transit time.

Persistent rectal prolapse in children: sclerotherapy and surgical management

Persistent rectal prolapse is an uncommon but distressing condition in children. Significant controversy exists regarding its surgical management. The aim of this study was to identify a successful management strategy for persistent rectal prolapse in the paediatric population. Records of all children with rectal prolapse treated surgically at Birmingham Children's Hospital between 1995 and 2003 were retrospectively reviewed. Demographic data, clinical presentation, investigations, treatment modality, complications, and outcome were recorded. Inclusion criteria for the study were failure of conservative management leading to operative treatment. An exclusion criterion was cystic fibrosis. A total of 24 patients with persistent rectal prolapse were identified. Two children with cystic fibrosis were excluded from the analysis. Children below the age of 5 years, group I (n=17), were successfully managed by submucous hypertonic saline injections. Eighty-three percent (14/17) were cured by injection sclerotherapy in this group, 12/14 (71%) requiring one injection and 2/14 requiring a second injection. In the three (17.6%) children in group I in whom sclerotherapy failed, cow's milk protein (CMP) allergy was identified as the causative factor. Children older than 5, group II (n=5), either had behavioural problems (n=3) or were autistic (n=2). This group of children with adult-type, full-thickness rectal prolapse were found to be refractory to initial attempts of injection sclerotherapy. All five children were successfully managed with surgical correction. We conclude that rectal submucous hypertonic saline injections are highly effective for managing early-onset idiopathic childhood rectal prolapse. CMP allergy should be considered in young children with recurrent rectal prolapse. We recommend early definitive corrective surgery in older children with persistent rectal prolapse, as they do not respond to conservative measures or injection sclerotherapy.

Gastrointestinal food allergy: new insights into pathophysiology and clinical perspectives

Adverse reactions to food that result in gastrointestinal symptoms are common in the general population; while only a minority of such individuals will have symptoms due to immunologic reactions to foods, gastrointestinal food allergies do exist in both children and adults. These immune reactions are mediated by immunoglobulin E-dependent and -independent mechanisms involving mast cells, eosinophils, and other immune cells, but the complexity of the underlying mechanisms of pathogenesis have yet to be fully defined. Knowledge of the spectrum of adverse reactions to foods that affect the digestive system, including gastrointestinal food allergy, is essential to correctly diagnose and manage the subset of patients with immunologically mediated adverse reactions to foods. Potentially fatal reactions to food necessitate careful instruction and monitoring on the part of health care workers involved in the care of individuals at risk of anaphylaxis. New methods of diagnosis and novel strategies for treatment, including immunologic modulation and the development of hypoallergenic foods, are exciting developments in the field of food allergy.

Lymphoid nodular hyperplasia and cow's milk hypersensitivity in children with chronic constipation

OBJECTIVE

To investigate the incidence of cow's milk allergy as evidenced by milk challenge and the findings of endoscopic and immunohistochemical examinations in children with chronic and refractory constipation.

STUDY DESIGN

Thirty-five study subjects (mean age, 8.3 +/- 3.3 years; range, 3-15 years; 17 girls) and 15 control subjects (mean age, 11.7 +/- 3.2 years; range, 2-15 years; 9 girls) were studied by colonoscopy and a 4-week cow's milk elimination and challenge.

RESULTS

Lymphoid nodular hyperplasia was the most prominent endoscopic finding in half of the subjects (46%), mostly occurring patchily in the transverse colon. Histologic findings other than lymphoid accumulation and mildly increased density of eosinophils were few. During the milk elimination and with supportive medication, 83% of subjects remitted. Constipation and/or other gastrointestinal or skin symptoms relapsed only in one third (34%) during the cow's milk challenge, these having significantly higher densities of intraepithelial gammadelta + T cells ( P <.001) in the biopsy samples of the terminal ileum as compared with the control subjects.

CONCLUSIONS

We were able to find formal evidence for the presence of cow's milk allergy in children with chronic constipation.

Cows milk consumption in constipation and anal fissure in infants and young children

OBJECTIVE

To examine daily cows milk consumption and duration of breastfeeding in infants and young children with anal fissure and constipation.

METHODS

Two groups of 30 consecutive children aged between 4 months and 3 years were evaluated retrospectively. Group I comprised children with chronic constipation and anal fissure in whom surgical causes were excluded, and group II comprised normal children. The daily consumption of cows milk, duration of breastfeeding and other clinical features of the children were investigated

RESULTS

The mean daily consumption of cows milk was significantly higher in group I (756 mL, range 200-1500 mL) than group II (253 mL, range 0-1000 mL) (P < 0.001). Group I children were breastfed for a significantly shorter period (5.8 months, range 0-18 months) than group II (10.1 months, range 2-24 months) (P < 0.006). The odds ratios for the two factors - children consuming more than 200 mL of cows milk per day (25 children in group I, 11 children in group II) and breastfeeding for less than 4 months (16 children in group I, 5 children in group II) - were calculated to be 8.6 (95% confidence interval [CI]: 0.23-0.74, P = 0.0005) and 5.7 (95% CI: 0.37-0.66, P = 0.007), respectively.

CONCLUSIONS

Infants and young children with chronic constipation and anal fissure may consume larger amounts of cows milk than children with a normal bowel habit. Additionally, shorter duration of breastfeeding and early bottle feeding with cows milk may play a role in the development of constipation and anal fissure in infants and young children.

Frequency of cow's milk allergy in childhood

OBJECTIVE

The primary objective of this review is to discuss the clinical features, diagnosis, natural history, and prognosis of cow's milk allergy in early childhood and its relationship to development of inhalant allergies.

DATA SOURCES

A review of 229 PubMed (National Library of Medicine) articles on cow's milk allergy (CMPA) for the years 1967 through 2001 was performed. In addition, references from other review articles have been included. This review represents a synthesis of these sources and the expert opinion of the author.

STUDY SELECTION

The expert opinion of the author was used to select the relevant data for this review.

RESULTS

The diagnosis of reproducible adverse reactions to cow's milk protein (CMP), ie, CMPA, has to be confirmed by controlled elimination and challenge procedures. The incidence of CMPA in infancy seems to be approximately 2 to 3% in developed countries. Symptoms suggestive of CMPA may be encountered in approximately 5 to 15% of infants emphasizing the importance of controlled elimination/milk challenge procedures. Reproducible clinical reactions to CMP in human milk have been reported in approximately 0.5% of breastfed infants. Most infants with CMPA develop symptoms before 1 month of age, often within 1 week after introduction of CMP-based formula. The majority has two or more symptoms from two or more organ systems. Approximately 50 to 60% have cutaneous symptoms, 50 to 60% have gastrointestinal symptoms, and approximately 20 to 30% respiratory symptoms. Symptoms may occur within 1 hour after milk intake (immediate reactions) or after 1 hour (late reactions). The prognosis of CMPA is good with a remission rate of approximately 45 to 50% at 1 year, 60 to 75% at 2 years, and 85 to 90% at 3 years. Associated adverse reactions to other foods develop in up to 50% and allergy against inhalants in 50 to 80% before puberty.

CONCLUSIONS

CMPA is the most common food allergy in early childhood with an incidence of 2 to 3% in the first year of life. The overall prognosis of CMPA in infancy is good with a remission rate of approximately 85 to 90%. In particular, gastrointestinal symptoms show a good prognosis. An early increased immunoglobulin E-response to CMP is associated with an increased risk of persistent allergy to CMP, development of adverse reactions to other foods, and development of asthma and rhinoconjunctivitis later in childhood.

Encopresis

A careful history and physical examination will help to differentiate between encopresis with or without constipation and fecal incontinence caused by anatomic or organic disease. Most children with encopresis with or without functional constipation require no or minimal laboratory workup. Successful treatment of encopresis requires a combination of parent and child education, behavioral intervention, medical therapy, and long-term compliance with the treatment regimen. The conventional treatment approach consists of behavior modification and laxative for children with encopresis with constipation and behavior modification alone for the few children with encopresis without constipation. Almost every patient will experience dramatic improvement in encopresis. Recovery rates are 30% to 50% after 1 year and 48% to 75% after 5 years.